Department of Health and Human 
Services

OFFICE OF

INSPECTOR GENERAL

A SURVEY OF CERTIFIED

NURSE-MIDWIVES

YlCE. 
Richard P. Kusserow 
INSPECTOR GENERA 
11 
'ol 
MACH 199 
daa  OFFICE OF INSPECfOR GENERA

The mission of the Office of Inspector General (OIG), as mandated by Public Law 95-452, as 
amended, is to protect the integrity of the Department of Health and Human Servces' (HHS)
programs as well as the health and welfare of beneficiaries served by those programs. This 
statutory mission is carried out through a nationwide network of audits, investigations, and 
inspections conducted by three OIG operating components: the Office of Audit Servces, the 
Office of Investigations, and the Office of Evaluation and Inspections. The OIG also informs 
the Secretary of HHS of program, and management problems, and recommends courses to 
correct them. 
OFFICE OF AUDIT SERVICE 
The OIG's Offce of Audit Servces (OAS) provides all auditing servces for HHS, either by 
conducting audits with its own audit resources or by overseeing audit work done by others. 
Audits examine the performance of HHS programs and/or its grantees and contractors in 
carrying out their respective responsibilities and are intended to provide independent 
assessments of HHS programs and operations in order to reduce waste, abuse, and 
mismanagement and to promote economy and efficiency throughout the Department. 
OFFICE OF INTIGATIONS 
The OIG's Office of Investigations (01) conducts criminal, civil, and administrative 
investigations of allegations of wrongdoing in HHS programs or to HHS beneficiaries and of 
unjust enrichment by providers. The investigative efforts of 01 lead to criminal convictions 
administrative sanctions, or civil money penalties. The 01 also oversees State Medicaid fraud 
control units which investigate and prosecute fraud and patient abuse in the Medicaid program. 
AN 
OFFICE OF EVALUATION  INSPECfONS 
The OIG's Offce of Evaluation and Inspections (OEI) conducts short-term management and 
program evaluations (called inspections) that focus on issues of concern to the Department 
the Congress, and the public. The findings and recommendations contained in these inspection 
reports generate rapid, accurate, and up-to-date information on the efficiency, vulnerability, 
and effectiveness of departmental programs. 
OEI's Atlanta Regional Offce staff prepared this report under the direction of Jesse J. 
Flowers, Regional Inspector General, and Christopher Koehler, Deputy Regional Inspector 
General. Principal OEI staff included: 
Paula Bowker, Co-project Leader  Jean DuFresne, Co-project Leader, Chicago 
Ron Kali  Angela Cole, RN 
Maureen Wilce  Ta Zitans, Headquarters  Department of Health and Human Servces

OFFICE OF

INSPECTOR GENERAL

A SURVEY OF CERTIFIED

NURSE-MIDWIVES

YlCE. 
tJ  Richard P. Kusserow 
INSPECTOR GENERA 
11 
~daa OEI-
04-90-02150  EXECUTIVE  SUMMAR 

PUROSE 
To describe the practices of certified nurse-midwives and what they perceive as 
barriers to their profession.

BACKGROUN 
A certified nurse-midwife (CNM) is a registered nurse who is educated in the two 
disciplines of nursing and midwifery, and who has been certified by the American 
College of Nurse-Midwives (ACNM). CNMs may provide prenatal care, intrapartum 
care, postpartum care, normal newborn care, and well-woman gyecology. 
Access to prenatal care and the nation s high infant mortality rate are growing national 
issues. Between 1988 and 1992, the Secretary, Department of Health and Human 
Servces, expressed strong conern about infant mortality, and he recently stated that all 
children deserve a "healthy start." In 1989 the nationwide infant mortality rate was 9. 
per 1000. In 1990 over one half milion pregnant women had little or no access to 
prenatal care. 
A decrease in physician obstetrical care providers throughout the nation exacerbates 
the problem of access to prenatal care. Many obstetrician/gyecologists (OB/GYNs) 
and family physicians no longer deliver babies largely due to fears of malpractice suits 
and many will not take Medicaid patients. 
Certified nurse-midwives (CNMs) can make prenatal care more accessible. They are 
historically credited with improving geographic distribution of care and providing care 
to underserved populations in inner cities and remote areas. 
METIODOWGY 
We mailed a survey questionnaire to a random sample of 542 CNMs residing in the 
United States. In addition, we reviewed the practice of 26 CNMs at 5 settings 
intervewed knowledgeable people, and reviewed literature on CNM practices and 
barriers. 
FININGS 
CN AR WELL QUALIFIED AN PRACTCE IN A WIE VARTY 
SETTGS 
Most CNMs are practicing their profession. 
Most CNMs are women who are well educated and have extensive 
experience in their profession.  Few CNMs work in rural areas.

CNMs provide servces in a variety of settings.

Most CNMs work for an organization or institution.

CNMs serve a wide range of patients.

CN  BARRS TO THIR PROFEION 
CIT 	
CNMs cite attitudes and perceptions of the medical community as the 
most important barrier to their profession. 
Other barriers frequently identified by CNMs included 
Limitations on prescriptive privileges 
, and 
Restrictive hospital admitting privileges
Attitudes and perceptions of the general public. 
CNMs who are closely affiliated with physicians and physician-governed 
organizations are less likely to cite barriers.  . . . . . . . . . . . . . . . . .. 
. ..  ..  ..  ..  ..  ..  ....    ....    ....    ....    ....    ....    ......  .  .........  .  ........  .  .........  .  ........  .  .........  .  .......     ....    ....    ....    ....    ....    ....    ....    ....    ....    ....    ....    ....    ....    .....     .....     .....     ....    ....    ....    ....    ....    ....    ..  ..  ..  ..  ..  ....  
TABLE OF CONTENTS

EXECU SUMY 
INODUCTON 
Purpose. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 
Definitions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 
Background 
Methodology  . . . . . . . . . . . . . 3 
FININGS 
AN 
CNMs ARE WELL QUALIFIED  PRACTICE 
IN A WIDE VARIETY OF SETTINGS  . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 
CNMs CITE BARRIERS TO THEIR PROFESSION  . . . . . . . . . . . . . . . . . 8 
APPENDIX 
Appendix A: Survey Questionnaire 
and Summary of CNM Responses to 
Each Question. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  . . . . . . . . .. A-
Appendix B: CNMs Provide Servces 
At A Variety of Sites  . . . .. B-
Appendix C: Sample Settings  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. C-
Appendix D: Barriers Identified As 
The Most Significant  . . . . . D-
Appendix E: Frequency of Selection of

Barriers Identified by CNMs 

Appendix F: Literature Review On 
Certified Nurse-Midwives' Profession  . . . . . . . . . . . . . . . . . . . . . . . . . . .. F
ENDNOTE  INTRODUCTION

PUROSE 
To describe the practices of certified nurse-midwives and what they perceive as 
barriers to their profession.

DEFIONS 
Certed Nurse-Midwe: A certified nurse-midwife (CNM) is a registered nurse who 
is educated in the two disciplines of nursing and midwifery. The Omnibus 
Reconciliation Act of 1987 defines "certified nurse-midwife" to mean a registered 
nurse who has successfully completed a program of study, including clinical experience 
in nurse-midwifery, has been certified by the American College of Nurse-Midwives 
(ACNM), and provides care for mothers and babies throughout the maternity cycle. 
CN 
Servces: CNMs may provide servces to normal, healthy women and their 
babies, including prenatal care; labor and delivery management; postpartum care; 
normal newborn care; and well-woman gyecology. 
Inant Mortty Rate: The infant mortality rate is the measurement of the number of 
deaths in the first year of life for every  The infant mortality rate is a 
1000 live births. 
generally-accepted indicator of the state of health care in 
a nation. 
BACKGROUN 
Midwiery and Prenata Cae 
A decrease in the number of physician obstetrical care providers throughout the 
nation exacerbates a problem of access to prenatal care, which "isl " the single factor 
most likely to prevent low birthweight babies and infant deaths. CNMs are 
historically credited with improving geographic distribution of care and providing care 
to underserved populations, care that would otherwse be unavailable in inner cities 
2 Three separate organizations
and remote areas. , the National Academy of Science 
Institute of Medicine, the Southern Governor s Association Task Force on Infant 
Mortality, and the Children s Defense Fund, have highlighted the contributions of 
CNMs to the prevention of low birthweight. 
Nurse-midwives have existed in this country since the 1920s.  In 1971 the American 
College of Nurse-Midwives (ACNM) officially established the profession 
of certified 
nurse-midwife (CNM) through a national certification examination which assesses the 
s. The Department of Health and Human Servces 
competency of each nurse-midwife
(HHS) grants reimbursement eligibilty under Medicaid and Medicare only to CNMs 
certified by ACNM. As of August of 1991, over 4500 nurse-midwives had been 
certified by ACNM.  The ACNM grants certification in nurse-midwifery to individuals who: 
, licensed in one of the United States or United States 
are registered nurses
territories; 
have graduated from a nurse-midwifery educational program approved, or with 
approval pending, by ACNM; and 
have achieved a passing score on the ACNM examination. 
In 1989 the American Hospital Association conducted a survey and found that of 2440 
responding hospitals, 11 percent employed CNMs and another 8 percent contracted 
with CNMs for their servces. 
In 1987 midwives attended only 2.6 percent of approximately four milion women who 
gave birth in U.S. hospitals.8 In 1988, midwives were the principal and only birth 
attendant for at least 70 percent of the births in European countries. We hope the 
information provided in this report will help the Department ascertain how CNMs 
might alleviate problems. 
Prenatal Cae and Inant Mortty 
Access to adequate prenatal care and the nation 
s high infant mortality rate are 
growing national issues. In 1989 the nationwide infant mortality rate was 9.8 per 1000. 
9 In 1990 over one half 
In 1987, the U.S. ranked 19th worldwide in infant mortality.
milion pregnant women had little or no access to prenatal care. 
Many obstetrician/gyecologists (OB/GYNs) no longer deliver babies largely due to 
ll and many 
fears of malpractice suits will not take Medicaid patientsP Family 
physicians are also discontinuing or decreasing the provision of obstetrical care. 
Governent Program to Decrease Inant Mortty 
The Secretary and other officials of HHS are concerned about infant mortality and are 
committed to developing programs and initiatives which address the problem. Various 
programs and organizations have been developed throughout this century to improve 
access to prenatal care and to lower the infant mortality rate. Some of the programs 
and organizations are highlighted below. 
In 1935, Title V of the Social Security Act authorized grants for maternal and 
child health. In 1981 Title V was amended, creating Maternal and Child 
Health Block Grants to provide consolidated funding for programs to reduce 
infant mortality.
 The Medicaid program began funding prenatal and postnatal care for low 
income women and infants in the 1960s. In recent years the program has been 
amended to expand servces. 
In the 1970s the Public Health Servces Act authorized grants for establishing 
Community Health Centers and Migrant Health Centers. These centers 
include perinatal and prenatal care among their servces. Beginning 
in Fiscal 
Year 1988, Congress appropriated funds for the Comprehensive Perinatal Care 
Program to improve pregnancy outcomes and the health status of women and 
infants who are served by Community and Migrant Health Centers. 
In 1974 the U. S. Department of Agriculture funded the first Supplemental 
Food Program for Women, Infants, and Children (WI C). This program, now 
nationwide, provides nutritional education and supplemental food to women 
who are at nutritional risk and are low-income, pregnant or nursing and infants 
and young children who are at nutritional risk. 
The Rural Health Clinic Servces Act authorized grants in 1977 which allowed 
clinics to provide CNM servces as defined under the Medicare program. 
The Omnibus Reconciliation Act of 1987 (OBRA 87) granted reimbursement 
eligibility to CNMs under the Medicare and Medicaid programs by expanding 
the definition of "mid-level practitioner. 
The Secretary, Department of Health and Human Servces, has initiated a 
Healthy Start" program. The program s purpose is to reduce infant mortality 
through additional support for comprehensive servce delivery. The HHS has 
made grants to fifteen communities for developing innovative approaches to 
achieve this objective. 
METIODOWGY 
To obtain information on CNM practices and barriers, we mailed a survey 
questionnaire to a random sample of CNMs. We also intervewed selected CNMs at 
their place of practice, and individuals in other organizations who are knowledgeable 
about CNM practices. Finally, we conducted a literature review of CNM practices and 
barriers. 
We obtained from ACNM a universe of 2985 CNMs who were ACNM members. 
From this universe, we randomly selected 542 CNMs residing in the United States. 
We mailed all 542 CNMs a survey questionnaire designed to obtain information on 
their practices and their perceptions of barriers to their profession. Four hundred and
six-
two CNMs responded to the survey questionnaire. We then eliminated 124 
CNMs who worked for the miltary, the Indian Health Servce (lHS), or who were not 
presently practicing as a CNM. We used responses from the remaining 338 CNMs for  our analysis of CNMs' practices and barriers to their profession. The 338 CNMs 
represent slightly more than 62 percent of our sample of 542. 
Our survey questionnaire contained three parts. The first part requested demographic 
information, such as age, salary range, years of experience, and sex. The second part 
contained a list of 14 possible barriers from which CNMs were instructed to select as 
many as they perceived to be a barrier to their profession. The third part contained 
the same 14 possible barriers, plus a category called "other" and one called " 
barriers." In the third part CNMs were instructed to choose the one most important 
barrier to their profession. Appendix A contains the entire survey instrument and a 
summary of sampled CNMs' responses to each question. 
To obtain a better understanding of CNM practices and barriers, we reviewed the 
practices of 26 CNMs at 5 employment locations. We also reviewed numerous 
published reports, articles, and papers on the practice of midwifery and barriers to 
that profession.

We obtained policy statements on midwifery from the American Hospital Association 
the American College of Obstetricians and Gynecologists and the American Academy 
of Family Physicians. We attempted to obtain a statement from the American Medical 
Association. However, we did not make a systematic attempt to determine the 
general view of physicians, hospitals, and other professionals or health care entities on 
the profession of midwifery. Our study is primarily based on the response of CNMs 
themselves.  FINDINGS

CN AR WELL QUALIFD AN PRACTCE IN A WIE VARTY 
SETTGS 
Th 
Most CNMs Are Practicig  Professin 
Of the 462 CNMs who responded to the survey, 78 percent (361) of them are 
actively engaged in their profession. 
Most CNMs Are Wome Wh Are Well Edated And Have Exene Exerie 
Thir Professin 
Ninety-nine percent of the CNM respondents were women and the majority held at 
least a Masters degree and had practiced their profession for at least six years. 
Approximately 61 percent of the CNMs held a Masters degree in Nursing and 
nearly two and a half percent held a Doctorate in Nursing. 
About 60 percent of the CNMs had practiced midwifery for 6 years or longer 
and twenty-six percent had between 11 and 20 years of practice. 
Most CNMs earned at least $30 000, and a few earned over $80 000. 
About 88 percent of the CNMs earned over $30 000 and almost 34 percent 
earned between $40 000 and $49 999. 
Less than one percent (.9 percent) earned over $80 000. 
Few CNMs Work In Rual Areas 
The vast majority of the CNMs practiced in urban and suburban areas. 
Six 
percent and 23 percent respectively worked in urban and suburban 
settings.

Only eleven percent practiced in rural areas.

CNMs Provi SelVices In A Variety Of Settgs 
Most CNM outpatient servces are provided in either the private offices of a physician 
or a CNM practice. 
Thirty-one percent of CNMs provided their outpatient servces in the private 
offices of either a physician or a CNM practice.  About 19 and 18 percent respectively practiced at community health centers 
and teaching hospitals. 
About 11 percent practiced at an HMO.

Small percentages (under 5 percent) of CNMs provided their outpatient

servces in freestanding birthing centers, hospital birthing centers or rooms, and 
homes. 
Less than one percent of CNMs provided outpatient servces in rural health 
centers. 
Most CNMs provided intrapartum (birth) care in traditional settings, such as hospital 
birthing centers, birthing rooms, or traditional hospital delivery rooms. 
Forty-five percent of CNMs provided intrapartum care in hospital birthing 
centers or birthing rooms. 
Twenty-nine percent and 5 percent respectively provided intrapartum care in 
traditional hospital delivery rooms and freestanding birthing centers. 
One and a half percent of the CNMs delivered babies at home because they

lacked hospital admitting privileges.

Only .6 percent said that they delivered babies at home by choice.

About 17 percent of the CNMs said they did not deliver babies at all.

Appendix B summarizes all settings where CNMs provide outpatient and intrapartum 
Servces. 
Institun 
Most CNMs Work For an Oranizatin or 
Most CNMs were employed full-time by hospitals and medical centers. Very few were 
self-employed or in partnership with other nurse-midwives.

Only 8 percent (25) of the 314 respondents who answered this question, worked 
independently as self-employed CNMs or in a partnership with 
other nurse-
midwives. 
Nearly half worked for a hospital or medical center. 
One CNM did not respond to this question, and 23 CNMs responded by reporting 
multiple, part-time employers rather than one full-time employer. These 24 people 
were not included in our analysis. The following chart shows full-time employers of 
314 of the 338 CNMs included in our analysis.  CN M Employers

46% Hospita or Medcal Centers 
5 % Colleges and 
Universities 
7% Public Health 
Agencies 
10% HMOs 
Self Employed or 
In Parershp with 
Other Nure-Midwives 
Appendix C provides a brief case study on CNM practices at each of five selected 
organizations. 
Patits 
CNMs Sere a Wzd Range of 
CNMs accepted both insured and uninsured patients, and a large percentage of them 
accepted Medicaid patients. 
Seventy percent of the CNMs responding to our survey questionnaire said they 
accepted Medicaid patients, and nine percent served Medicare patients. 
About 21 percent said they provided uncompensated care. 
Six-
two percent said they had self-paying patients.

Six-one percent said they had third-party payer patients and thirty-two

percent served HMO patients.
 , "
CN 
CIT BARRS TO THIR PROFEION 
CNMs Consred Att An  Medal Commit 
Barr  Pereptins Of  Th To Be 
Most Signifcant 
We asked the CNMs to select the most important barrer from a list of 
14 possible 
barriers. Three hundred and seventeen of the 338 CNMs responded to this question. 
They selected attitudes and perceptions of the medical community as the most 
significant barrier. The CNMs cited a lack of physician support as the primary reason 
for medical community attitudes and perceptions being a barrier. Appendix D 
summarizes the most important barriers identified by 317 of the 338 CNMs responding 
to our survey questionnaire, ranked in order of importance. 
Medical community attitudes and perceptions may also have an impact on other 
barriers discussed below--particularly prescriptive privileges and hospital admitting 
privileges. 
Our examination of the policies of key medical organizations indicates that there is a 
basis for CNMs' perceptions. These organizations discourage independent CNM 
practices as a matter of policy. For example, the American Medical Association 
resolved in 1985 to "oppose new legislation extending medical practice to nonphysician 
"14 Likewise
providers. , the American Academy of Family Physicians (AAP) issued a 
policy statement in 1990 which said, in part: 
The AAP believes that ideally obstetrics should be practiced only by fully 
licensed, qualified physicians, however, the AAP recognizes that the practice 
of medicine has many aspects and utilizes many resources in the responsible 
delivery of quality health care. 
Further  The AAP is strongly opposed to independent practice of obstetrics 
and gyecology by nonphysicians. 
Finally, "The CNM should not function independently as a health care 
practitioner. The AAP believes that the certified nurse-midwife should only 
function as part of the health care team which includes a physician qualified in 
obstetrics. The certified nurse-midwife should be employed only as a means of 
providing limited care, always under the direction and responsible supervsion 
of a practicing, licensed physician with all reimbursement for servces being 
through the responsible supervsing physician. 
Th 
CNMs Cie Other Important Barrrs To  Professin 
We asked CNMs to choose from the sarne list of 14 possible barriers all those which 
they perceived as barriers to their profession. They also provided reasons for choosing 
a barrier. The barriers identified most frequently were:  Litations on prescrptie prieges: Six-four percent of the CNMs sampled 
said their lack of prescriptive privileges is a barrier. Authority to independently 
prescribe, administer, and dispense drugs, immunizing agents, and devices 
necessary for the practice of midwifery is limited by State and local laws and 
regulations. Some CNMs included vitamins in these privileges. 
Communty atttudes and perceptions: Six percent of the CNMs said 
community attitudes and perceptions is a barrier. CNMs sampled said how the 
general public perceives and comprehends their capabilties and 
servces can 
limit their practices. 
Medica communty atttudes and perceptions: Fifty-six percent of the CNMs 
said medical community attitudes and perceptions is a barrier. The CNMs 
cited lack of physician support as the primary reason for this barrier, which can 
influence many other barriers. As discussed above, when asked to select the 
single most important barrier to their profession, nearly 24 percent of the 
CNMs cited medical community attitudes and perceptions. 
Restrctions on hospita admttg prieges: Forty-three percent of the CNMs 
said lack of hospital admitting privileges is a barrier. Privileges are granted by 
a hospital governing board to allow health professionals to admit patients in 
their own name. CNMs said hospital policy may preclude them from admitting 
patients. 
Medica malpractce insurance: Malpractice insurance may become an 
important barrier to CNM practices. The 338 CNMs responding to our survey 
questionnaire ranked malpractice insurance eighth out of 14 barriers. However 
if a recently proposed increase of between 45 and 47 percent in medical 
malpractice insurance premiums is approved, it could become a more 
important barrier for CNMs. The effective date of the increased rates has 
been delayed from August 1, 1991 pending further negotiations. 
CNMs earning less than $30 000 and between $70- 000 cited malpractice 
insurance as a barrier (59 percent and 50 percent respectively) more frequently 
than CNMs in other salary ranges. Malpractice insurance is more frequently 
perceived as a barrier by CNMs who are in partnership with physicians, self-
employed, or in partnership with other nurse-midwives than by CNMs in other 
employer categories. 
Appendix E summarizes all of the barriers identified by the 338 CNMs responding to 
our survey questionnaire. The barriers are ranked based on the number of CNMs 
who selected them.  CNMs Wh Are Closely Affted Wih Physins and Physin-goveme Oranizations 
Le  Barr 
Are  Likly To Pereie 
Perceived barriers are influenced in part by employer. The table below shows the 
eight major employers of CNMs. The table further shows that CNMs who were 
closely affilated with physicians or medical organizations were less likely to perceive 
barriers to their practices than were those CNMs who worked more independently, 
such as the self-employed.

Of the 338 responding CNMs, 314 identified their full-time employers and 298 of 
those said they worked for one of eight major employers listed in our questionnaire. 
The remaining 16 said they worked for small employers--consolidated in our 
questionnaire in a category called "other. 
CN IDENTG BARR 
PERCENT OF 
Medica 
Communty  Communty  Hospital
Employer  Number  Prescrptie Atttudes &  Atttudes &  Admttg
of  Prieges  Perceptions  Perceptions  Prieges 
Self-Employed  100 
College or 
University  100 
Partnership 
with Nurse-
Midwife 
Partnership 
with Physician 
Hospital or 
Medical 
Center  145 
Public Health 
Agency 
HMO 
Physician 
Practice 
Other 
TOTAL  314  Twenty-one CNMs said there are no barriers to their profession, regardless of 
employer, but most of them were clearly associated with the medical community. 
Fifteen of the 21 worked for a hospital, medical center, physician, or other medical 
organization. Three worked for a college or university. Two worked for someone 
other than one of the eight major employers identified in the survey questionnaire. 
Only one self-employed CNM said there were no barriers. 
Our review of the literature tended to corroborate our findings relating to CNM 
practices and barriers. Appendix F summarizes our literature review findings.  APPENDIX A

SURVEY QUETIONNAI
SUMY  CN 
OF  REPONSES TO EACH QUETION  ----   -- 
STATE OF PRIMAY PRACTICE SITE 

FEMAE -- MAE 
GENDER  334  (Total: 338)

AGE

24 or YOUNGER 
25 - 29 
30 - 39 
-1 
40 - 49 
50 or OLDER 
ARE YOU CURRENTLY IN CLINICAL PRACTICE AS A CNM? 
338  YES 
124 NO: 
WHY NOT? PLEASE CHECK ONLY ONE RESPONSE. 
I AM A STUDENT 
I AM RETIRED 
-L 
MAPRACTICE INSURACE NOT AVAILABLE OR 
PREMIUMS TOO HIGH 
CNM INCOME TOO LOW 
-L 
LACK OF HOSPITAL ADMITTING PRIVILEGES 
LACK OF PRESCRIPTIVE PRIVILEGES 
-L 
LACK OF HEALTH CARE PERSONNEL FOR 
RELIEF 
LICENSE REVOKED/SUSPENDED 
OTHER (PLEASE EXPLAN): 
IF YOU ANSWERED "NO" TO THS QUETION STOP HERE 
MTAH B ACK THS GUIE IN TH ENCWSED P, OPLESE TAGE PAI ENVWPE.
YOU. 
A 
 ------------      
WHO EMPLOYS YOU AS A PRACTICING CNM?

145 HOSPITAL OR MEDICAL CENTER

-1 
COLLEGE OR UNIVERSITY

HEALTH MANTENANCE ORGANIZATION

U. S. PUBLIC HEALTH SERVICE 
TITLE V FUNDED PUBLIC HEALTI AGENCY 
OTHER PUBLIC HEALTH AGENCY 
PHYSICIA-OWNED PRACTICE 
PARTNERSHIP WITH PHYSICIA(S)

PARTNERSHIP WITH NURSE-MIDWIVES

-- SELF-EMPLOYED

MILITARY

INDIA HEALTH SERVICE

OTHER (SPECIFY): 
337: 23 CNMs showed multiple, part-time employers and were not included 
for a total of 314 respondents 
INIA RETI  PLEE 
IF YOU ANSWERED "MIITARY" OR " SERVICE" 
STOP HERE AN MTAH BA CK THS GUIE IN TH ENaDSED POSTAGE 
PAI ENVWPE. 
YOU. 
CHACTERIZE THE GEOGRAHIC AREA IN WHICH YOU WORK: 
... URBAN

SUBURBAN

RURA

330 
CNM Discussion Guide 
A  .. 
------   
WHT 
IS THE POPULATION OF THIS AREA? 
LESS THA 10 000 
-- 10
000 - 49 999 
-A 50 000 - 99 999 
100 000 - 499 999 
500 000 - 999 999 
000 000 - 4 999 999

-- 5
000 000 OR MORE

CHECK HIGHEST EARNED NURSING DEGREE.

DIPLOMA IN NURSING

-1 
ASSOCIATE DEGREE IN NURSING

BACHELOR' S DEGREE IN NURSING

207  MASTER' S DEGREE IN NURSING 
DOCTORATE IN NURSING

337

WHICH OF THE FOLLOWING CNM EDUCATION PROGRAS DID 
YOU ATTEND?

PRE-CERTIFICATE PROGRA

CERTIFICATE PROGRA

MASTER' S DEGREE PROGRA

DOCTORA PROGRA 
OTHER 
CNM Discussion Guide 
A  ----------     
10.	 DID THE SCHOOL YOU ATTENDED FOR YOUR CNM EDUCATION 
HA VB A PLACEMENT PROGRA FOR CNMs? 
YES  302 
11.	 DID YOU RECEIVE FINANCIA ASSISTANCE FROM ANY OF THE 
FOLLOWING SOURCES FOR CNM EDUCATION? 
PHYSICIA OR CLINIC SPONSOR

HOSPITAL SPONSOR

-2 	
STATE SCHOLARSHIP OR GRAT 
STATE LOAN REPAYMENT 
MILITARY 
NATIONAL HEALTH SERVICE CORPS SCHOLARSHIP 
NATIONAL HEALTH SERVICE CORPS LOAN REPAYMENT 
-1 
FEDERA NURSING EDUCATION LOAN REPAYMNT 
FEDERA NURSING EDUCATION SCHOLARSHIP 
INDIA HEALTH SERVICE

OTHER FEDERA SCHOLARSHIP OR GRANT 
FEDERAL LOAN REPAYMENT 
OTHER (SPECIFY): 
CNM Discussion Guide 
A  .. 
-. 
-- 
WHT 
12.  IS YOUR APPROXIMATE ANNUAL SALARY FROM YOUR 
CNM PRACTICE? (EXCLUDE BENEFITS AND MAPRACTICE 
INSURACE COSTS).

LESS THA $20 000

-. $20 000 - $29 999

$30 000 - $39 999

-1 
.. $40 000 - $49 999

-- $50 000 - $59 999

-1 $60 000 - $69 999

-- $70 000 - $79 999

-- $80 000 OR MORE

332 
MA 
13.	 SINCE YOUR CERTIFICATION, HOW  TOTAL YEARS HAVE 
YOU PRACTICED AS A CNM? 
THA 
LESS  1 YEAR

1 - 5 YEARS

100  6 - 10 YEARS 
11 - 20 YEARS 
THA 
MORE  20 YEARS

338

CNM Discussion Guide 
A  ------   
.-..  %%
WHT 
14.	 PERCENTAGE OF YOUR CLIENTS ARE COVERED BY: 
(numbers represent CNMs who recorded a percentage in each category) 
236  MEDICAI 
MEDICARE 
205  PRIVATE THIRD-PARTY PAYER 
.1 %	 HEALTH MANTENANCE ORGANIZATION 
SELF-PAY 
-1%	
UNCOMPENSATED CARE

CHAPUS

-1%	
DON'T KNOW

OTHER (SPECIFY):

15.	 WHERE DO YOU PROVIDE THE MAJORITY OF OUTPATIENT 
.SElR VICES? (PLEASE CHECK ONLY ONE SETTING)
PRIVATE OFFICE (PHYSICIA OR CNM PRACTICE) 
-1 
FREESTANDING BIRTHING CENTER 
HOSPITAL BIRTHING CENTER 
HOME 
HEALTH MANTENANCE ORGANIZATION 
COMMUNITY HEALTH CENTER 
-- MIGRA 
HEALTH CENTER

-- RURA 
HEALTH CENTER

TEACHING HOSPITAL

OTHER HOSPITAL 
OTHER (SPECIFY): 
333 
CNM Discussion Guide 
A  ----  
16.	 WHERE DO YOU PROVIDE THE MAORITY OF INTRAARTUM 
CARE? 
(PLEASE CHOOSE ONLY ONE SETTING)

-5 
DO NOT DELIVER

-1 
HOSPITAL BIRTHING CENTER

-2 
HOSPITAL TRAITIONAL DELIVERY ROOM

-L 
HOME - BY CHOICE

HOME - DO NOT HAVE HOSPITAL ADMITTING PRIVILEGES 
FREESTANDING BIRTHING CENTER 
OTHER (SPECIFY): 
329 
CNM Discussion Guide 
A  -- -----.--    
AN 
PLEASE CHECK  ITEMS BELOW WHICH YOU PERCEIVE TO BE A 
BARRIER TO YOUR CNM PRACTICE. THEN CHECK THE MAN REASON 
WHY THIS IS A BARRIER TO YOUR PRACTICE. CHOOSE ONLY ONE 
REASON. 
-H 
17.	 REIMBURSEMENT BY MEDICAID 
WHY? 
PAYMENT TOO LOW 
ALL SERVICES NOT COVERED (MOST IMPORTANT 
SERVICE NOT COVERED): 
-- CAN'T OBTAIN IDENTIFICATION NUMBER 
DELAYED PAYMENTS

OTHER (EXPLAIN): 
18.  REIMBURSEMENT BY MEDICARE 
WHY? 
PAYMENT TOO LOW 
-1 
ALL SERVICES NOT COVERED (MOST IMPORTANT 
SERVICE NOT COVERED): 
CAN'T OBTAIN IDENTIFICATION NUMBER 
DELAYED PAYMENTS

OTHER (EXPLAIN): 
CNM Discussion Guide 
A  ....  .. 
-----------.--       
19.  PRIVATE THIRD-PARTY REIMBURSEMENT 
WHY? 
PAYMENT TOO LOW 
ALL SERVICES NOT COVERED (MOST IMPORTANT 
SERVICE NOT COVERED): 
DELAYED PAYMENTS 
FEW PRIVATE INSURERS REIMBURSE CNMs FOR 
SERVICES 
OTHER (EXPLAIN): 
20.  PRESCRIPTIVE PRIVILEGES 
WHY? 
CAN'T GET DEA NUMBER 
LIMITED BY STATE OR LOCAL LAWS/REGULATIONS 
OTHER (EXPLAIN): 
21.  142  HOSPITAL ADMITTING PRIVILEGES 
WHY? 
LIMITED BY STATE OR LOCAL LA WS/REGULATIONS 
120  LIMITED BY HOSPITAL POLICY 
OTHER (EXPLAIN): 
CNM Discussion Guide 
A  ------   
22.  STATE LAWS AND REGULATIONS 
WHY? 
SCOPE OF SERVICES LIMITED (MOST IMPORTANT 
SERVICE LIMITED): 
-1 
OPTIONS FOR PRACTICE SETTING LIMITED 
-2 
OTHER (EXPLAIN): 
-1 
23.  LOCAL LAWS AND REGULATIONS 
WHY? 
SCOPE OF SERVICES LIMITED (MOST IMPORTANT 
SERVICE LIMITED): 
OPTIONS FOR PRACTICE SETTING LIMITED 
OTHER (EXPLAIN): 
24.  AVAILABILITY OF PHYSICIA BACKUP 
WHY? 
NO PHYSICIA(S) IN GEOGRAHIC AREA
J. 
PHYSICIA(S) UNWILLING TO SERVE AS BACKUP. 
WHY? 
-1 
OTHER (EXPLAIN): 
CNM Discussion Guide  ---------.     
-- 
-2 
25.  COST OF PHYSICIA BACKUP 
WHY? 
COST IS TOO HIGH 
(How much do you pay for physician backup? 
i.e. $400 delivery or $4000 per month) 
PAYMENT SCHEDULE IS DIFFICULT 
(i.e. per month or delivery) 
OTHER (EXPLAN): 
-2 
26.  REQUIREMENTS OF PHYSICIA BACKUP 
-2WH Y?
PHYSICIA MUST BE CONSULTED FOR TOO MAY 
COMMON OR STANDARD PROCEDURES 
PHYSICIA MUST BE IN HOSPITAL DURING DELIVERY 
REQUIREMENTS ARE UNCLEAR 
OTHER (EXPLAN): 
J1 
27.  MAPRACTICE INSURACE 
-1WH Y?
IS NOT AVAILALE

COVERAGE IS LIMITED

COST IS TOO HIGH

OTHER (EXPLAN):

CNM Discussion Guide 
A  .. 
----------     
-2 
28.  CONTINUING EDUCATION 
WHY? 
TOO MAY UNITS ARE REQUIRED 
-1 CAN'T GET TIME OFF TO OBTAIN CONTINUING 
EDUCATION UNITS 
NONE OFFERED IN MY AREA 
OTHER (EXPLAIN): 
29.  MEDICAL COMMUNITY ATTITUDES AND PERCEPTIONS 
WHY? 
LACK OF PHYSICIA SUPPORT 
LACK OF NURSE SUPPORT 
-1 
LACK OF OTHER HEALTH CARE PERSONNEL 
SUPPORT 
-1 
OTHER (EXPLAIN): 
30.  202  COMMNITY ATTITUDES AND PERCEPTIONS 
WHY? 
NEGATIVE MEDIA COVERAGE 
-1 
POPULATION UNAWARE OF CNM CAP ABILITIES AND 
SERVICES 
102	 POPULATION DOES NOT DISTINGUISH BETWEEN LAY 
MIDWIVES AND CNMs 
OTHER (EXPLAIN): 
CNM Discussion Guide 
A  31.  PLEASE LIST AND EXPLAN ANY OTHER BARRIERS TO YOUR 
PRACTICE AS A CNM. 
CNM Discussion Guide 
A  ----------------        
32.	 BELOW ARE LISTED ALL OF THE ABOVE MENTIONED POSSIBLE 
BARRIERS. PLEASE CHECK THE MOST IMPORTANT BARRIER TO 
YOUR CNM PRACTICE. CHOOSE ONLY ONE. 
REIMBURSEMENT BY MEDICAID

REIMBURSEMENT BY MEDICARE

-1 
PRIVATE THIRD-PARTY REIMBURSEMENT

.2 	
PRESCRIPTIVE PRIVILEGES 
HOSPITAL ADMITTING PRIVILEGES

-1 
STATE LAWS AND REGULATIONS

-L 
LOCAL LAWS AND REGULATIONS

AVAILABILITY OF PHYSICIA BACKUP 
COST OF PHYSICIA BACKUP

REQUIREMENTS OF PHYSICIA BACKUP 
-1 
MAPRACTICE INSURACE

CONTINUING EDUCATION

-1 
AN 
MEDICAL COMMUNITY ATTITUDES  PERCEPTIONS 
COMMUNITY ATTITUDES AND PERCEPTIONS 
-1 	
OTHER 
NO BARRIERS 
317 
CNM Discussion Guide 
A  33.	 WHT ARE SOME SOLUTIONS TO THE BARRIERS YOU 
EXPERIENCE AS A CNM? 
34.	 PLEASE SUPPLY ANY ADDITIONAL INFORMATION THAT YOU 
THINK WOULD BE HELPFUL TO UNDERSTANDING THE PRACTICE 
OF NURSE-MIDWIFERY. 
TH 
MA 
YOU FOR COMPLETIG THS GUIE. NOW  IT BACK IN 
TTHI E NCWSED POSTAGE PAI ENVWPE. WE APPRECIATE YOUR
AN EFFORT IN HELPING US CONDucr THS STUY. 
CNM Discussion Guide 
A  APPENDIX 
CN 
PROVIE SERVICE 
SIT 
AT A VARTY OF 
Out  atient Servce Site  # of CNMs  Percent 
Private Office of a Physician

or a CNM Practice  102  31.0 
Community Health Center  19. 
Teaching Hospital  17. 
HMO  11.2 
Other Hospital 
Freestanding Birthing Center 
Hospital Birthing Center/Room  1.5 
Home 
Rural Health Center

Other 
330 *  100 
Intra  artum Care Site  # of CNMs  Percent 
Hospital Birthing Center/Rooms  148  45. 
Hospital Traditional Delivery Room  28. 
Do Not Deliver  17.3 
Freestanding Birthing Center 
Home-Do not have hospital 
admitting privileges  1.5 
Home-By choice 
Other 
329 **  100 
* Of 338 CNMs, 330 answered this question 
** Of 338 CNMs, 329 answered this question  APPENDIX C

SAMLE SETTGS 
We reviewed practices of 26 CNMs at five employment locations to gain an 
understanding of variation in CNM practices. Our observations are summarized 
below. 
Medica School Hospita: Baylor College of Medicine, Department of Obstetrics and 
Gynecology, Houston, Texas 
Twelve CNMs practice at the medical school hospital, at an associated public city 
hospital and at county-run clinics. The CNMs see approximately 8000 patients 
annually in the practice. They provide prenatal, perinatal, well-infant and some 
gyecological care to mostly low-income, Medicaid-eligible, hispanic patients. Eighty-
five percent of the deliveries performed by the CNMs are uncompensated. 
Texas law does not give CNMs explicit prescriptive privileges. It authorizes physicians 
to "delegate" those privileges. CNMs may admit patients to a hospital with a 
physician s approval within 24 hours. Barriers for these CNMs are minimized because 
their back-up physicians are also Baylor employees, and are readily available to 
provide assistance. Malpractice insurance is provided through the college, which is 
self-insured. 
CN: 
Parership with  Catawba Nurse Midwives, Inc., Rock Hil, South Carolina 
This practice is a partnership of three CNMs and a fourth CNM employed by the 
partners. The CNMs provide prenatal servces to over 50 patients, a day at a county 
health department clinic, which contracts for the CNMs' servces. Ninety percent of 
the patients receive Medicaid. Some private insurance companies will reimburse 
CNMs for their servces but some will not. 
Some procedures, such as lab servces and ultra-sound tests, must be done off-site at a 
doctor s office or at a laboratory which accepts Medicaid patients. Although CNMs 
cannot prescribe medicines, including vitamins, they may dispense certain medicines 
which clinics keep on hand. 
About 45 babies are delivered each month at a nearby hospital, the Piedmont Medical 
Center. The CNMs must admit patients under the names of three doctors who Serve 
as their back-up. Many doctors in the community accept CNMs and their practice; 
however, some pediatricians have refused to see babies delivered by CNMs. The 
CNMs pay for their own malpractice insurance. 
C - 1
 Physician-Owed Priate Practice: Comprehensive Obstetrics, Gynecology, & 
Midwifery, Hinsdale, Ilinois 
Four CNMs work for this physician-owned corporation. The CNMs provide a full 
range of well-woman care in two private medical offices. Most of the patients are 
healthy, white, middle and upper income women who have made a conscious choice to 
be cared for by a CNM. Over 
80 percent of the patients have private insurance. 
Biling is done under a physician s name. 
The CNMs and a physician deliver around 23 babies a month at two nearby private 
hospitals. State laws recognize and license CNMs as nurses only. CNMs must admit 
patients under a physician s name and a physician must be in the hospital during 
deliveries. CNMs may only prescribe certain drugs through delegated physicians 
orders, and all prescriptions must be cosigned by a physician. 
The physician-owned corporation pays for the CNMs' malpractice insurance through a 
company that provides malpractice insurance for CNMs nationwide. The 
corporation s malpractice insurance carrier attempted to impose a surcharge on the 
policy for working with CNMs. This surcharge was challenged in court and prohibited. 
Freestadig Birhig Center: Holy Family Servces, Weslaco, Texas 
Three CNMs practice at a freestanding birth center, which is run by the Catholic 
Diocese of Brownsville. The CNMs provide prenatal outpatient and educational 
servces to over 400 patients a month. A consulting doctor has an office on site, which 
allows certain prescription drugs to be kept on site. Five other consulting physicians 
have left the practice due to malpractice 
insurance surcharges. 
CNMs deliver over 20 babies in the center s four birthing rooms each month. CNMs 
make two home visits for each mother and baby. Ninety-five percent of the center 
patients are hispanic, and many delay seeking prenatal care. Half of the patients are 
covered under Medicaid. Some patients and their familes work off their debt to the 
clinic by doing janitorial work or 
other work for the center. A health insurance 
company for the largest employer in the area will not reimburse CNM servces to 
employees of that company. 
Health Maitenance Organtion: Anchor Health Maintenance Organization 
Chicago, Ilinois 
The Health Maintenance Organization (HMO) employs four CNMs. They provide 
outpatient obstetrical and gyecological servces at the HMO. CNMs and physicians 
take a team approach to patient care. Approximately 95 percent of the CNMs 
C - 2
 patients are enrollees in the HMO. The remainder are self-paying or uncompensated 
care patients. 
CNMs perform over 25 percent of the 40-50 deliveries occurring monthly at an 
associated hospital. The six HMO staff physicians must admit patients 
to the hospital 
and be in immediate proximity at the time of delivery. CNMs may not write 
prescriptions but may write refil orders which one of the doctors must sign. The 
HMO carries "umbrella" malpractice insurance covering all of its employees--including 
CNMs. 
C - 3
 APPENDIX D

BARRS 
ENTiFIED AS TH MOST SIGNICAN 
RAK 
BARRIER  # OF CNMs 
Medical Community Attitudes 
and Perceptions  23. 
Prescriptive Privileges  16. 
Hospital Admitting Privileges  8.8 
Availabilty of Physician Backup  8.2 
Community Attitudes & Perceptions 
Malpractice Insurance

Reimbursement by Medicaid 
Requirements of Physician Backup  4.4 
State Laws and Regulations 
Private Third-Party Reimbursement 
Local Laws and Regulations 
Continuing Education 
Reimbursement by Medicare 
Cost of Physician Backup 
89. 
CNMs who said "no barriers 
CNMs who chose "other 
317*  100 
* Of 338 responding CNMs, 317 answered this question 
D - 1  APPENDIX E

FRQUENCY OF SEIECTON OF
BARRS 
ENTIFIED BY 
BARRIER AND MAJOR CONCERN  # OF CNMs 
Prescriptive Privileges: Limited by 
State & Local Laws & Regulations  218 
Community Attitudes & Perceptions: Population 
Unaware of CNM Capabilties & Servces  202 
Medical Comm. Attitudes & Perceptions: 
Lack of Physician Support  189 
Hospital Admitting Privileges: Limited 
by Hospital Policy  142 
Reimbursement by Medicaid: Payment Too Low  141 
Private Third-Party Payer Reimbursement: 
Few Private Insurers Reimburse CNMs  135 
Availability of Physician Backup: Physi
cians Unwillng to Serve as Backup  119 
Malpractice Insurance: Cost Too High  111 
Requirements of Physician Backup: Physi
cian Must Be in Hospital During Delivery 
Continuing Education Units: Can t Get 
Time Off To Obtain 
State Laws & Regulations: Scope of 
Servces Limited

Reimbursement by Medicare: Payment 
Too Low 
Cost of Physician Backup: Cost Too High 
Local Laws & Regulations: Options for 
Practice Setting Limited 
E - APPENDIX 
MIWI' 
LITRATU REVIW ON CERTiFIED NUSE- PROFEION 
Our literature review showed a significant body of information on barriers 
to certified 
nurse-midwives' (CNMs ) profession. The literature also provided information on 
numerous other aspects of CNMs' profession , including impact of CNMs' practices on 
access to care and infant mortality, quality and cost-effectiveness of CNM services, and 
a need for further publicity and research regarding the work of CNMs. 
CN Ca 
Help Aleviate Problems Of Accss To Cae And Inant Mortty 
CNMs can provide care to underserved populations and improve access for 
those populations. 
CNMs are historically credited with improving geographic distribution of care. 
According to a 1986 report by the Office of Technology Assessment, CNMs can 
provide safe care that would otherwse be unavailable in inner cities and 
remote areas. 
A 1981 "Journal of Nurse-Midwifery" article on infant mortality reported that 
high-risk women in other countries have a better opportunity to obtain in-depth 
medical attention than such women have in America. The 
system in other 
countries relies heavily on nurse-midwives and America s system relies on 
obstetrical care.

The maternity system in this country is fundamentally flawed and overly 
complex according to the Institute of Medicine. Their 1988 report said that we 
need a new system dedicated to drawing all women into prenatal care. Further 
this new system should use physicians and CNMS. 
Midwives have a positive impact on preventing low birthweight and reducing 
infant mortality.

In 1984 a "Public Health Report" article on out-of-hospital births concluded 
that, regardless of a mother s age group, babies delivered by midwives were less 
18 Likewise
likely to be low birthweight. , researchers for the American College 
of Nurse-Midwives Foundation reported in 1986 that when nurse-midwives were 
used in previously underserved areas, maternal and infant mortality and 
morbidity were reduced. This occurred irrespective of whether the delivery 
occurred at home or in a hospital setting. 
A 1971 study reported in the American Journal of Obstetrics and Gynecology 
showed that when a nurse-midwife program was installed in a hospital 
prematurity and neonatal death rates decreased and pregnant women kept 
F  , " , "
more prenatal care appointments. When the program was terminated, the 
prematurity and neonatal death rates rose. 
In countries with a lower rate of infant mortality than the United States, well 
trained midwives provide the majority of family planning and obstetrical care. 
An article in "Journal of Nurse-Midwifery" showed in 1981 that if we hope to 
improve pregnancy outcomes and decrease infant mortality in this country, we 
must increase the number of nurse-midwives and expand their servces. 
In 1988, a representative of the World Health Organization testified before the 
u. S. Commission to Prevent Infant Mortality, stating that  Every country in 
Europe with perinatal mortality and infant mortality rates lower than the 
United States uses midwives as the principal and only birth attendant for at 
least 70% of all births." Further  The United States should spend far less 
money on interventionist obstetric care and put more resources into building up 
a large strong midwifery position."22 
CN 
Ca Provide Qualty And Cost-Effecte Health Cae 
CNMs can provide quality care within their area of competence. 
The quality of CNM care is equivalent to physicians' care within their area of 
competence, according to a 1986 study by the Office of Technology Assessment. 
Further, they are better than physicians at providing servces which depend on 
communications with patients and preventative action. 
The "American Journal of Obstetrics and Gynecology" reported in 1976, that 
outcomes for CNMs pertaining to prenatal period, labor, and delivery were not 
significantly different from those for physicians with two exceptions. CNMs 
patients were far more likely to keep prenatal care appointments and 
physicians reported a higher rate of forceps deliveries. The study concluded 
that, in a hospital setting, the care of low-risk maternity patients provided by 
CNMs was as effective as that of physicians. 
A 1986 Office of Technology Assessment report stated that CNMs can manage 
normal pregnancies safely and can manage them as well as, if not better than 
physicians. Finally, given that quality is equivalent, it would appear to be cost-
effective to use nonphysicians rather than physicians. 
A 1988 Canadian study of birth outcomes showed that 
nurse-midwives provide 
prenatal care to low-risk women that is comparable, if not superior, to the care 
provided by family physicians. Also, nurse-midwives provide more adequate 
and comprehensive care to pregnant women than family 
physicians do. 
Another study, conducted by an HMO in 1989, showed that CNMs do not 
adversely affect maternal and perinatal mortality rates, and were an unqualified 
success as part of the obstetrical team. 
F  , "
Nurse-midwives can provide cost effective care in certain contexts. 
Nurse-Midwifery in America " a report published by the American College of 
Nurse-Midwives in 1986, stated that normal pregnancies managed by nurse-
midwives in freestanding birth Centers cost 40 percent of the traditional 
obstetrical care costs. Furthermore, a CNM practice operating at full capacity 
can provide less costly maternal and infant care. 
The American College of Nurse-Midwives Foundation 
s 1986 report described 
Mter 
the effects of a nurse-midwife program in four rural Georgia counties. 

the program was implemented, perinatal care expenses and infant mortality 
rates decreased. 
Payroll costs were reduced by 13 percent in the obstetrics and gyecology 
department of an HMO through the use of CNMs. However, in an office 
setting CNMs did not generate a 
significant savings. 
Atttudes And Perceptions Of Medica Communty And General Public Are Barers 
CN' 
To  Profession 
CNMs may not be readily accepted within medical communities. 
CNMs have encountered difficulty in gaining acceptance by practicing 
physicians, medical societies, and hospital departments. For example, according 
to a 1986 Office of Technology Assessment study on nonphysicians, OB/GYNs 
are threatened by CNM 
practices. Such physicians are no longer sole providers 
of prenatal and obstetrical care and must compete with CNMs. 
Likewise, the Boston Globe published an April 1991 article by the 
Massachusetts Medical Society President who discouraged practices by 
nonphysicians. He said  We should not attempt to solve the access problems 
for medical care by expanding the role of the limited-licensed practitioners."32 
In 1986, the American College of Nurse-Midwives (ACNM) reported that 
physicians directly influence barriers to CNMs practices. Those who oppose 
the practice of nurse-midwifery are tightening the financial noose via denial of 
hospital privileges, restrictive state statutes and regulations, and harassment of 
supportive physicians. 
CNMs may not be well understood by the general public. 
CNMs' practices and servces are not well understood by the general public and 
health-care decision makers. The American College of Nurse-Midwives 
(ACNM) reported in 
1986 that a lack of information about nurse-midwives 
the most important barrier to making CNM servces 
available in the country. 
F  The ACNM also reported that the general public had a poor understanding of 
nurse-midwives. 
Further, a 1989 study on one HMO showed that over 50 percent of patients 
surveyed lacked knowledge of CNMs. However, they expressed receptiveness 
to CNMs after learning their role and qualifications. 
In order to help each woman make an informed decision regarding birth care 
and technology, the roles and servces of all birth care providers, including 
CNMs, should be publicized throughout a community, according to a World 
Health Organization (WHO) article published in Lancet in 1985. The WHO 
encourages governments to act as coordinator in assessing birth technology and 
disseminating information about that technology at alllevels. 
Further Research Is Needed On The Roles And Practces Of 
The cost and effect of CNM care should be documented. 
According to numerous authoritative organizations, there is a need for more 
research and more data about all facets of CNM roles and practices. For 
example, in 1982 the General Accounting Office reported a general lack of data 
to evaluate use, or Federal effort to encourage use, of nurse-midwives. 
The American College of Nurse-Midwives Foundation recommended in their 
1986 report that studies be conducted to record the contributions of nurse-
midwives to care for the poor, to measure the effect of nurse-midwifery care on 
health-care costs, and to document the effect of nurse-midwifery care on the 
health of mothers, babies and the familes served. Further, the Foundation 
recommended increased documentation of client satisfaction with and the safety 
and quality of care received from nurse-midwives.

Further, in 1988 the National Commission to Prevent Infant Mortality 
recommended that demonstration projects be undertaken to test innovative 
ways to increase participation of physicians and CNMs in Medicaid and 
underserved communities.

Physician attitudes should be studied and analyzed. 
The American College of Nurse-Midwives stated in 1986 that we cannot make 
assumptions regarding the attitudes and behaviors of physicians practicing 
4o A physician stated in a 
obstetrics. 1986 article in the Journal of Nurse-
Midwifery that before we can hope to bring physicians and midwives into closer 
relationships we need some good research about physician attitudes so we know 
exactly what the problem is. 
F  ENDNOTES

C. Everett Koop, MD. Transcript #5 of "A Time for Change" dated April 29 
1991. Televised on PBS stations by the MacNeil/Lhrer Productions. 
Office of Technology Assessment. "Nurse-Practitioners, Physician Assistants 
Certified Nurse-Midwives: A Policy Analysis " Health Technology Case Study 
, December 1986. 
American College of Nurse-Midwives. "Contributions of CNMs To Improved 
Health Outcome " PR89-12/05, 1989. 
Kenneth E. Bell, MD, and Jack I. Mils, PhD. "CNM Effectiveness in the 
HMO Obstetric Team " Obstetrics and Gynecology, 74, 112-116, 1989. 
American College of Nurse-Midwives. "4260 Nurse-Midwives Certified by the 
ACNM " PR90-1/26, 1990. 
American College of Nurse-Midwives, PR90-1/26, 1990, and ACNM memo 
dated August 12, 1991. 
American College of Nurse-Midwives, PR90-1/26, 1990. 
American College of Nurse-Midwives. "Nearly 100 000 1987 Births in U. 
Hospitals Attended by Certified Nurse-Midwives - Up 500% From 1975 
PR90-2/15, 1990. 
Advisory Panel on National Health Policy, American College of Nurse-
Midwives. "National Health Policy Background Papers " February 1990. 
10.	 Koop. 
11.	 Dana Hughes and Sara Rosenbaum. "An Overvew of Maternal and Infant 
Health Servces in Rural America " The Journal of Rural Health, Volume 5 
Number 4, October 1989. 
12.	 Physician Payment Review Commission. Annual Report to Congress, 1991. 
13.	 Hughes and Rosenbaum. 
14.	 Office of Technology Assessment. 
15.	 Office of Technology Assessment.  16.  Doris Haire. "Improving the Outcome of Pregnancy Through Increased 
Utilzation of Midwives " Journal of Nurse-Midwifery, 26(1), 1981. 
17.  American College of Nurse-Midwives. "Recent Reports Recommend Increased 
Use of Certified Nurse-Midwives " PR89-12/05, 1989. 
18.  Eugene R. DeClercq, PhD. "Out-of-Hospital Births, U.  , 1978: Birth Weight 
and Apgar Scores as Measures of Outcome " Public Health Report, 99/1, 1984. 
19.  Judith Rooks, CNM, MPH, MS, Editor and J. Eugene Haas, PhD, Editor. 
Nurse-Midwifery in America " A Report of the American College of Nurse-
Midwives Foundation, 1986. 
20.  C. Slome, MD, DPH; H. Wetherbee, MPH; M. Daley, MSPH, PhD; K. 
Christensen, RN, MPH; M. Meglen, CNM, MS; and H. Thiede, MD. 
Effectiveness of CNMs: A Prospective Evaluation Study," American Journal of 
Obstetrics and Gynecology, 124
, 1976. 
21.  Haire. 
22.  Nancy E. DeVore, CNM, MS, and Bertrand M. Bell, MD. "Midwifery and the 
Shortage of Obstetrical Care Providers." Presented on October 24, 1989 at the 
meeting of the American Public Health Association
, p. 8. 
23.  Office of Technology Assessment. 
24.  Slome. 
25.  Office of Technology Assessment. 
26.  Lynn Buhler, BSN, Msc; Ned Glick, PhD; Samuel B. Sheps, MD, MSc, FRCPC. 
Prenatal Care: A Comparative Evaluation of Nurse-Midwives and Family 
Physicians " Canadian Medical Association Journal
, 139/5, 1988. 
27.  Bell and Mils. 
28.  Rooks and Haas. 
29.  Rooks and Haas. 
30.  Bell and Mils. 
31.  Office of Technology Assessment. 
32.  Barry M. Manuel. "Who Should Prescribe Drugs? " The Boston Globe, April 
, 1991.  33.  Rooks and Haas, p. 113. 
34.  Rooks and Haas
, p. 2. 
35.  Bell and Mils. 
36.  World Health Organization (WHO). "Appropriate Technology for Birth 
Lancet, VoL 2, 1985, p. 436. 
37.  General Accounting Office (GAO). "The Availabilty of Nurse-Midwife 
Servces Under Various Federal Health Care Programs " GAO-HRD-82
1982. 
38.  Rooks and Haas, p. 42. 
39.  American College of Nurse-Midwives, Recent Reports Recommend Increased 
use of Certified Nurse-Midwives, PR89-12/05, 1989. 
40.  Rooks and Haas, p. 65. 
41.  Irvn Cushner, MD. 'The Health Care Team-A Physician s Perspective 
Journal of Nurse-Midwifery, 31, 1986.