Department of Health and Human Services


OFFICE OF


INSPECTOR GENERAL


A SURVEY OF CERTIFIED


NURSE-MIDWIVES


YlCE. 

Richard P. Kusserow 

INSPECTOR GENERA 11 

'ol daa MACH 199 
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. 

OFFICE OF EVALUATION AN 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 CIT 	 BARRS TO THIR PROFEION 

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 

Restrictive hospital admitting privileges, and 

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 

CNMs ARE WELL QUALIFIED AN 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. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. AAppendix B: CNMs Provide Servces 

At A Variety of Sites . . . .. BAppendix C: Sample Settings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. CAppendix D: Barriers Identified As 

The Most Significant . . . . . DAppendix E: Frequency of Selection of


Barriers Identified by CNMs 


Appendix F: Literature Review On 

Certified Nurse-Midwives' Profession . . . . . . . . . . . . . . . . . . . . . . . . . . .. FENDNOTE 
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 1000 live births. The infant mortality rate is a 

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 is "the single factor 

most likely to prevent low birthweight babies and infant deaths."l 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 

and remote areas.2 Three separate organizations, 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 

competency of each nurse-midwifes. The Department of Health and Human Servces 

(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: 

are registered nurses, licensed in one of the United States or United States 

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. 

In 1987, the U.S. ranked 19th worldwide in infant mortality.9 In 1990 over one half 

milion pregnant women had little or no access to prenatal care. 

Many obstetrician/gyecologists (OB/GYNs) no longer deliver babies largely due to 

fears of malpractice suitsll and many 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 

Most CNMs Are Practicig Th 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. 

Most CNMs Work For an Oranizatin or Institun 

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 nursemidwives. 

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. 

CNMs Sere a Wzd Range of Patits 

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 Pereptins Of Th Medal Commit To Be 

Most Signifcant Barr 

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 

providers."14 Likewise, 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. 

CNMs Cie Other Important Barrrs To Th 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, selfemployed, 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 

Are Le Likly To Pereie Barr 

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. 

PERCENT OF CN IDENTG BARR 

Medica 

Employer Number 

of 

Prescrptie

Prieges 

Communty 

Atttudes & 

Perceptions 

Communty 

Atttudes & 

Perceptions 

Hospital

Admttg

Prieges 

Self-Employed 100 

College or 

University 100 

Partnership 

with NurseMidwife 

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 OF CN REPONSES TO EACH QUETION 
STATE OF PRIMAY PRACTICE SITE 


GENDER 334 FEMAE -- MAE (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, PLEE STOP HERE 

MA BACK THS GUIE IN TH ENCWSED POSTAGE PAI ENVWPE. TH 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 

IF YOU ANSWERED "MIITARY" OR "INIA RETI SERVICE" PLEE 

STOP HERE AN MA BACK THS GUIE IN TH ENaDSED POSTAGE 

PAI ENVWPE. TH 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 ­
. .

12. WHT 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


.. $40 000 - $49 999


-- $50 000 - $59 999


-1 $60 000 - $69 999


-- $70 000 - $79 999


-- $80 000 OR MORE


332 

-1 

13.	 SINCE YOUR CERTIFICATION, HOW MA TOTAL YEARS HAVE 

YOU PRACTICED AS A CNM? 

LESS THA 1 YEAR


1 - 5 YEARS


100 6 - 10 YEARS 

11 - 20 YEARS 

MORE THA 20 YEARS


338


CNM Discussion Guide 

A ­
.. % 

14.	 WHT 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 

SERVICES? (PLEASE CHECK ONLY ONE SETTING) .l 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 ­
.

PLEASE CHECK AN 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. 

17.	 -H 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): 

23. -1 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 
. 

25. -2 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): 

26. -2 REQUIREMENTS OF PHYSICIA BACKUP 

WHY? -2 PHYSICIA MUST BE CONSULTED FOR TOO MAY 

COMMON OR STANDARD PROCEDURES 

PHYSICIA MUST BE IN HOSPITAL DURING DELIVERY 

REQUIREMENTS ARE UNCLEAR 

OTHER (EXPLAN): 

27. J1 MAPRACTICE INSURACE 

WHY? -1 IS NOT AVAILALE


COVERAGE IS LIMITED


COST IS TOO HIGH


OTHER (EXPLAN):


CNM Discussion Guide 

A ­
..

28. -2 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 MEDICAL COMMUNITY ATTITUDES AN 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 YOU FOR COMPLETIG THS GUIE. NOW MA IT BACK IN 

TH ENCWSED POSTAGE PAI ENVWPE. WE APPRECIATE YOUR TI AN EFFORT IN HELPING US CONDucr THS STUY. 

CNM Discussion Guide 

A ­
APPENDIX 

CN PROVIE SERVICE 

AT A VARTY OF SIT 

Out atient Servce Site 

Private Office of a Physician


or a CNM Practice 

Community Health Center 

Teaching Hospital 

HMO 

Other Hospital 

Freestanding Birthing Center 

Hospital Birthing Center/Room 

Home 

Rural Health Center


Other 

Intra artum Care Site 

Hospital Birthing Center/Rooms 

Hospital Traditional Delivery Room 

# of CNMs Percent 

102 31.0 

19. 

17. 

11.2 

1.5 

330 * 100 

# of CNMs Percent 

148 45. 

28. 

Do Not Deliver 

Freestanding Birthing Center 

Home-Do not have hospital 

admitting privileges 

Home-By choice 

Other 

17.3 

1.5 

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. Eightyfive 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. 

Parership with CN: 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: Physicians Unwillng to Serve as Backup 119 

Malpractice Insurance: Cost Too High 111 

Requirements of Physician Backup: Physician 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 

LITRATU REVIW ON CERTiFIED NUSE-MIWI' 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 

likely to be low birthweight.18 Likewise, 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 costeffective 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 nursemidwives 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 

the effects of a nurse-midwife program in four rural Georgia counties. 
 Mter 

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 

To CN' 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 nursemidwives 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 

obstetrics.4o A physician stated in a 1986 article in the Journal of NurseMidwifery 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 NurseMidwives. "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 NurseMidwives 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.