American Nurse-Midwifery: A Hyphenated Profession with a Conflicted Identity

I do not like the phrase nursing and midwifery. . . .To me it implies that midwifery is specialized nursing. It is nursing. -Comment on Committee on Organization questionnaire, 1954(1) No other country except the United States is struggling with the mistaken concept that midwifery is nursing or that midwifery is an extension of nursing. We are midwives with a nursing background. -Lucille Woodville, 1974(2) I totally agree that we [nurse-midwifery] must stay within nursing. A divided house will not be able to withstand strong opposition and change. -Sharon Rising, 1973(3) We always knew we were two different professions. -Ernestine Wiedenbach, CNM, 1979(4) Beginning with their Progressive Era origins as hyphenated professionals, nurse-midwives have been divided over their primary professional identification. Identifying with either their nursing background or their midwifery specialization, they debated whether their practice was a nursing specialty or an independent profession. As this disagreement intensified in the 1970s, the survival of their national association, the American College of Nurse-Midwives (ACNM), was threatened.5 After 4 divisive years, professional self-interest prevailed and membership accepted a compromise that reaffirmed the separate profession of nurse-midwifery, placed the origins of its knowledge base in both nursing and medicine, and affirmed the role of the ACNM as nurse-midwifery's national organization responsible for setting educational and practice standards. The compromise permitted the national organization to continue its work, but the controversy did not end and continues to divide nurse-midwives today. In 1994 the ACNM first approved a route for non-nurses, or direct entry midwives, to be educated in association-approved programs. Upon graduation they could sit for the same national certification exam as graduate nurse-midwives; after passing the exam they received the title "Certified Midwife" (CM). In 1997 ACNM members unanimously voted to extend membership to CMs and to call the practice of CMs and Certified Nurse-Midwives (CNMs) midwifery. In 1998, a proposal was made to change the organization's name to the American College of Midwifery, debate was heated. Those in favor wanted to name the practice, not the professional, so as to be inclusive of all members. Arguments against the name change focused on the importance of nursing to both practice and practitioners of professional midwifery. In the end two-thirds of the membership voted to defeat the proposed name change, and division over primary professional identity remained unresolved.6 In this analysis of professional identity I expand the understanding of the importance of the orthodoxy "once a nurse, always a nurse" in the professional identity conflict of nurse-midwives. In so doing, I broaden Patricia D'Antonio's analysis of nursing, gender, and power from the sphere of the hospital staff nurse to the sphere of what she calls the "new nursing roles" developing in the 1960s.7 I argue that nurse-midwives' overriding identification with nursing made it difficult for these specialists, first educated in nursing, to completely adopt a new professional identity. This failure framed nurse-midwives as medically oriented in the minds of 1960s women who, out of distrust for mainstream medicine, wanted to control their childbirth experiences. These women turned instead to self-educated middle-class peers, the vanguard of modern direct entry midwifery.8 The development of a strong primary nursing identification was cultivated in nursing schools by educators who followed in the tradition of working to wrest control of education and ptactice from medicine.9 Perhaps it was this preoccupation with differentiating clinical nursing practice from medicine, in the quest for professional autonomy, that prevented nursing leadership from accepting the work of early advanced practitioners-nurse anesthetists and nurse-midwives-as nursing care. …