A Career in Nurse-Midwifery

The American College of Nurse-Midwives, With women, for a lifetime®

A Career in Nurse-Midwifery

Presented to the 61st Annual Convention of the National Student Nurses Association

April 5 & 6, 2013By

Elaine Germano, CNM, DrPH, FACNMSenior Education Policy Advisor

American College of Nurse-Midwives


What is a Certified Nurse-Midwife?

• An advanced practice nurse educated in the two professions of nursing and midwifery

• Licensed to practice and prescribe in all 50 states, DC and most US Territories

• Provides primary care to women across the lifespan, including care during pregnancy and childbirth


Midwifery: An Ancient Profession


Mary Breckinridge Founded the Frontier

Nursing Service (FNS) in1925

Sent British nurse-midwives on

horseback to isolated families in Appalachia


FNS midwives cared for women and families in their homes in Appalachia

• In order to improve the health of families, we must first care for the mothers


The Growth of Midwiferyis supported by publishedresearch that shows CNMs:

• Provide high-quality care• Have comparable or better

outcomes• Have high levels of patient

satisfaction• Lower costs due to fewer

interventions


Nurse-midwives provide primary care to women across the lifespan


So, What Exactly Do Nurse-Midwives Do?

• Well-Woman Annual Exams– Menstrual and sexual

history, along with family, medical and social history

– Physical exam, including breast and pelvic exams

– Pap test, STI screening– Lab, diagnostic tests– Prescriptions


Midwives also provide: • Primary Care Visits

– Minor complaints, e.g. colds, flu, urinary tract infections

– Headache, depression, diabetes, thyroid conditions, etc

– Counseling (including preconception counseling)


Prenatal Care

• Regular individual or group visits• Partners encouraged to attend!• Vital signs, lab and diagnostic tests • Fetal Assessment (heart tones, fundal height)• Nutritional/exercise assessment


Labor and Birth Attendance


Post-partum care and Breastfeeding support


A Typical Day in the Office• First patient:

– First visit of 26 year old woman, 1st pregnancy, LMP 2/22/12, EGA 6w1d

– c/o urinary frequency and intermitant R-sided pain, 7 on scale of 10; decreased appetite

– Denies vag bldg, nausea, vomiting or other sx• Gather additional data:

– PMH, PSH, Gyn hx, Ob hx, Soc hx– Allergies, Meds, Pre-pregnancy wt


First Patient (cont.)• Gather objective data:

– VS, ht, wt, BMI – Labs – PE– transvaginal u/s

• What are your concerns?– Ectopic pregnancy– Medications– UTI


First Patient (cont)• Assessment

– 26yo GIP0, EDD 12/1/13– IUP GA 6w1d– UTI

• Management Plan– Tx UTI– Counsel re: exercise, diet, expected wt gain,

medications; stage of pregnancy expectations


Second Patient• Returning client

– 19yo female, taking ocps x2 mos, c/o bloating, breast tenderness, thinking of stopping pills; also c/o vag discharge x5 d

– Denies vag itching or d/c, admits to some dysparuina and dysuria, unsure about partner sx

• Gather additional data:– Review hx, any changes incl. change in partner?– Use of condoms, correct use of ocps?


Second Patient (cont.)• Gather objective data:

– VS, wt– Labs, incl. wet prep + GC/CT, UA– Pelvic exam

• What are your concerns?– UTI– STIs– Correct use of ocps


Second Patient (cont.)• Assessment

– BV, Trichomoniasis– At risk for pregnancy

• Management Plan– Tx STI and vag. infection– Counsel re: use of condoms, continuing current

ocps, consider change in 1 month


Additional Patients• 52yo woman c/o perimenopausal sx, smoker,

wants HRT• 33yo G3P2, 20 wks GA, no concerns, 28 lb wt

gain• 28yo G2P2, IUD Paragard x3 yrs c/o excessive

bleeding and lower abd pain• 27yo G2P1, 37 wks GA, normal pregnancy,

tired of being pregnant, wants induction


Healthy Mothers, Healthy Babies, Healthy Families


Philosophy of Care• Listening to women – the hallmark of midwifery

care• Focus on prevention and education• View pregnancy as a normal process• Provide compassionate and family-centered

care• Encourage women’s participation in

decision-making• Use technology and intervention appropriately• Consultation, collaboration and referral with

members of the health care team


Midwives promote the health and well-being of women and infants within their families and

communities


Emphasis on Primary Care

Reproductive Care(53.3%)

Primary Care(33.1%)

Labor and Birth(13.6%)


Antepartum

Intrapart

um

Postpart

um

Newborn

Gyneco

logy

Primary

Care0%

10%20%30%40%50%60%70%80%90%

100%

Scope of Practice of Full-Time Midwives


CNMs Have Excellent Outcomes

00.5

11.5

22.5

33.5

4

Infant Mortality

NeonatalMortality

LowBirthweight

CNMsMDs


Midwives Provide Effective Labor

Support• Twice as much ambulation in labor• Twice as much intermittent

monitoring• Twice as many non-medicated births• Half as many episiotomies• Supportive care during labor


Midwifery Prenatal Care Contributes to Excellent

Outcomes

Midwifery Prenatal Care

Listen to Women

Provide Emotional

Support

Pregnancy and Birth

Education

Collaborate with Physicians


Patients Prefer Practices with CNM Providers

0

20

40

60

80

100

%

Satisfied Use Again

CNMs

NoCNMs


Where do midwives attend births?

Hospital Birth Center Home0

102030405060708090

10096.1

2.1 1.7

%


Planned Home Birth: A Safe Option

with ACNM Midwives• Low Infant Mortality - 2.5 per 1000• Transfer to hospital during labor- 8.3%• Postpartum/Neonatal Transfers - 1.9%


Number of CNM-Attended Births


Reimbursement for CNMs

• Medicaid: mandatory coverage of CNMs in all states

• Medicare: sets standard for all private insurance, CNMs at 100% of physician fee schedule

• Private insurance: mandated coverage of CNM services in 33 states


Primary Employers

• Hospitals and medical centers: 35%• MD practices: 30%• Community health centers: 8.4%• Midwife Practice: 7%• Academic Institution: 7%• Other: 12.6%


Salary

• Full-time (35 hrs per wk or greater) average $114,152 per year

• Productivity bonus: 25 % receive, 75% do not


The American College of Nurse-Midwives

• The professional association representing CNMs and Certified Midwives (CMs)

• Since 1929 - oldest women's health care organization in the US

• Ensures foundation of midwifery education through the Core Competencies for Basic Midwifery Practice

• Sets Standards for the Practice of Midwifery• Provides Clinical Bulletins


ACNM’s Department of Global Outreach

• Since 1982 – projects and technical assistance in 30 developing countries

• Devised Life Saving Skills Training Program used in Asia and Africa

• Assists and strengthens midwifery associations


Midwifery Education• 39 midwifery education

programs nationwide• Most onsite; 5 fully

distance-based• Bridge programs (ADN

to MSN)• Master’s programs• DNP programs


Associa

te, Nursi

ng

Associa

te, Not N

ursing

Bachelor's

, Nursi

ng

Bachelor's

, Not N

ursing

Master's

, Nursi

ng

Master's

, Midwife

ry

Master's

, Public

Health

Master's

, Other

Doctorat

e, Any T

ype

0

10

20

30

40

50

60

Earned Degrees of CNMs and CMs (%)


Midwifery Education Trends


2008 2009 2010 2011 20120

50

100

150

200

250

300

350

400

450

500

320 325344

398

474

The Number of New CNM/CMs Has Risen 48% Since 2008Source: American Midwifery Certification Board


Midwifery Certification• National certification exam administered by

American Midwifery Certification Board• Graduate Degree required in order to take

certification exam• Number of ever-certified CNMs/CMs more

than 12,000• Recertification every five years


Learn More…• Learn more about midwifery at

www.midwife.org• See http://midwife.org/become_midwife.cfm

for midwifery education information• Visit http://midwife.org/find.cfm to find a

midwife in your area• See www.gotmom.org for ACNM’s online

breastfeeding resource


With Women…

…For a Lifetime


The American College of Nurse-Midwives

www.midwife.org

Documents

A Career in Nurse-Midwifery