PRESERVING MIDWIFERY PRACTICE IN A MANAGED CARE ENVIRONMENT

PRESERVING MIDWIFERY PRACTICE IN A MANAGED CAREENVIRONMENT*

Deanne R. Williams, CNM, MS, FACNM

ABSTRACT

Since 1925 when nurse-midwifery emerged as a new healthprofession in the United States, and over the past 30 yearsunder the auspices of the American College of Nurse-Midwives(ACNM), national standards for education, certification, andpractice have enabled nurse-midwives to provide the quality ofcare that is highly valued by policy-makers and consumers. Thispaper describes the education and practice of over 7,000midwives who have received national certification throughmechanisms developed by the ACNM, describes the strengthsof the profession, and reviews the impact of managed care onthe practice of midwifery. Also highlighted is ACNM’s devel-opment of a partnership, with the Maternal and Child HealthBureau, to study the impact of changes in the health careenvironment on pregnant women and ACNM certified mid-wives. This partnership is presented as an example of how theACNM has evolved into an organization that is well-positionedto preserve midwifery in a managed care environment. JNurse Midwifery 1999;44:375–83 q 1999 by the AmericanCollege of Nurse-Midwives.

INTRODUCTION

Nurse-midwifery was established as a new health profes-sion in the United States in 1925. Since its inception, itsmembers have been providing safe and cost-effectivehealth care with a focus on disease prevention andhealth promotion. Indeed, these practitioners wereamong the first providers of the basic tenets of “man-aged” and “primary” care and this was long before suchqualities would become valued by health care policy-makers. Based on this history, one would predict that thepractice of midwifery† would flourish in today’s managedcare environment. In some instances, this is preciselywhat has happened. Despite increasing evidence thatmidwifery care is high quality, accessible, and cost-effective, however, it has not been universally adopted as

a model for the delivery of health care in managed caresettings.

Under the auspices of the American College of Nurse-Midwives (ACNM), nurse-midwives have establishedstandards for education, certification, and practice thatenable them to provide the quality of care valued byconsumers. This paper describes the evolution of theACNM from a fledgling association to a professionalorganization that is positioned to help preserve mid-wifery in a managed care environment for the good ofthe women, children, and families that midwives† arecommitted to serve. It also identifies areas where morehelp is needed from federal and state government agen-cies to assure access to midwifery care. One of theACNM’s recent federal partnership initiatives, which willprovide new national data and promote statewide col-laboration around the impact of managed care on preg-nant women, is also described. This paper focusesspecifically on the over 7,000 certified nurse-midwives(CNMs) and certified midwives (CMs)† nationwide whohave been educated in programs accredited by theACNM and certified through mechanisms developed bythe ACNM.

BIRTH OF A NEW HEALTH PROFESSION IN THEUNITED STATES: NURSE-MIDWIFERY

For almost 75 years, nurse-midwives have providedcomprehensive health care to some of the nation’s mostvulnerable women and families. In addition, they haveoffered integrated and accessible health care services toclients across all socioeconomic strata, developed sus-tained partnerships with their patients, practiced in thecontext of family and community, and have been ac-countable for addressing a large majority of personalhealth care needs. In other words, they have practicedmidwifery in a primary care context (1).

Although the individual and collective accomplish-ments of many midwives have been remarkable, noneare as historically significant to the evolution of Ameri-can midwifery in this century as those of Breckenridge.This intrepid pioneer and visionary can be credited forthe establishment of nurse-midwifery as a profession inthe United States (2). The work of Mary Breckenridgeand the nurses and midwives of rural Appalachia’sFrontier Nursing Service (FNS) during the early 1900s is

Address Correspondence to Deanne R. Williams, CNM, MS, FACNM,Executive Director, American College of Nurse-Midwives, 818 Con-necticut Avenue, NW Suite 900, Washington, DC 20006.

* This article is based on a paper presented at a session on“Midwifery in the Managed Care Market,” held during the 126thAnnual Meeting of the American Public Health Association, Washing-ton, DC, November 16, 1998.

† CNMs, CMs and midwives as used herein refers to those midwiferypractitioners who are certified by the American College of Nurse-Midwives (ACNM) or the ACNM Certification Council, Inc; midwiferyrefers to the profession as practiced in accordance with the standardspromulgated by the ACNM.

Journal of Nurse-Midwifery • Vol. 44, No. 4, July/August 1999 375

q 1999 by the American College of Nurse-Midwives 0091-2182/99/$20.00 • PII S0091-2182(99)00069-5Issued by Elsevier Science Inc.

an awe-inspiring story and an important event in thehistory of United States health care. The FNS storybrings to life the heart of a woman who chose aphysically and emotionally demanding job over a life ofprivilege, and exemplifies the very essence of a profes-sion which has built its reputation on a commitment tofamily-centered care and whose slogan has becomeListen to Womenw.

Midwives who follow in the footsteps of Breckenridgeoften call upon stories of her accomplishments whensearching for answers to modern dilemmas and, remark-ably, find little to add to her formula for success. Al-though not formally educated in epidemiology, Brecken-ridge conducted herself as a skillful public healthprofessional. She conducted an extensive needs assess-ment in remote Kentucky that documented an alarmingmaternal and infant mortality rate. She then proceededto collect data about the women served by FNS andthose data were, ultimately, used to evaluate the qualityof nurse-midwifery care (3). In the role of statistician, sheused the FNS outcome data to argue that more nurse-midwives were needed to provide access to quality carefor the nation’s impoverished families. Breckenridge wasalso keenly aware of the need to assure funding andcommunity support in order to sustain services; thus, shebecame a community activist and successful fundraiser.She was one of the first health care providers to docu-ment the value of including the community in the designand evaluation of services while the nationwide system ofperson-to-person fundraising she established is still inexistence.

Apart from these many accomplishments, it wasBreckenridge’s decision to send public health nursesfrom the United States to England to be trained asmidwives that most significantly impacted the develop-ment of professional midwifery in the 20th century. Heradoption of the British model for the formal education ofmidwives led to the establishment of nurse-midwiferyeducation programs in this country.

THE BIRTH OF A PROFESSIONAL ORGANIZATION:THE AMERICAN COLLEGE OF NURSE-MIDWIVES

Incorporated in 1955, the ACNM’s mission is to pro-mote the health and well-being of women and infants

within their families and communities through the devel-opment and support of the profession of midwifery aspracticed by CNMs and CMs (4). As such, the ACNMadvocates for programs and policies that improve thehealth of all women and babies, supports the publicationof a peer-reviewed journal, develops numerous publica-tions designed by and for midwives, supports an activepublic relations campaign, maintains a continuing com-petency assessment program, and takes formal positionson issues relating to midwifery and women’s health.

The ACNM also works with many individuals andorganizations around the world to promote safe moth-erhood and midwifery. As a member of the InternationalConfederation of Midwives and through work funded bythe U.S. Agency for International Development, theACNM has earned an international reputation for theprovision of high quality technical assistance in efforts todecrease maternal mortality in developing countries andthroughout the United States. In 1998, the ACNMinitiated a partnership with six other organizations topromote safe motherhood within the United States. TheSafe Motherhood Initiatives—USA envisions that allpregnancies are intended, that all women will completechildbirth strengthened, and that no woman will die or beharmed as a result of being pregnant.

NATIONAL STANDARDS FOR ACCREDITATIONAND CERTIFICATION

Since 1962, the ACNM has set the standards for theaccreditation of nurse-midwifery education programs,and in 1994 this responsibility was expanded to includethe accreditation of basic midwifery education programsthat educate qualified non-nurses. The decision to de-velop a mechanism to accredit midwifery educationprograms that do not require a nursing credential wasdebated for a number of years. The success of a numberof accelerated programs, which offer nursing and mid-wifery education concurrently, provided reassurance thatnew models could be developed and implemented.

Since 1971, graduates of accredited education pro-grams have been required to pass an entry-level nationalcertification examination which tests the knowledge re-quired for safe, beginning-level practice. The nationalexamination measures a minimum level of knowledge,and is used as a critical screening tool for entry intopractice. One of the ACNM hallmarks for midwiferyeducation, the Core Competencies for Basic MidwiferyPractice, was first developed in 1978. The core compe-tency document, which is updated every five years,described the scientific knowledge and clinical skillsexpected of each graduate of an accredited program andserves as the blueprint to construct the certificationexamination. In order to attain and maintain accredita-tion status, each education program must document in a

Deanne Williams, Executive Director of the American College ofNurse-Midwives, Washington, DC, received a bachelor of sciencedegree in nursing from the University of New Mexico and amaster of science degree and nurse-midwifery education from theUniversity of Utah. Since 1980, she has held a number ofadministrative, clinical, and faculty positions in midwifery. Shereceived a U.S. Public Health Service Primary Care PolicyFellowship in 1994 and in 1998, served as a member of theUCSF Center for the Health Professions Taskforce on Midwifery.

376 Journal of Nurse-Midwifery • Vol. 44, No. 4, July/August 1999

written report and demonstrate to a site visitor team howit teaches, measures, and/or evaluates each compe-tency. This system is designed to assure that graduatesfrom accredited programs throughout the country havebeen tested on their ability to perform the same set ofskills and to meet minimum standards for exercisingjudgment when managing patient care (5).

The ACNM Division of Accreditation (DOA) hasbeen recognized by the U.S. Department of Educationsince 1982 and is responsible for developing andmaintaining accreditation criteria for both nurse-mid-wifery and basic midwifery education programs. AllDOA programs must be directed by a midwife (CNMor CM) who is certified by the ACNM CertificationCouncil, Inc. (ACC). In addition to being either a CNMor CM, all faculty must have at least one year ofclinical midwifery experience, must maintain currencyin clinical practice, and must meet ACNM requirements forcontinuing competency. All programs must be affiliatedwith an institution of higher education (5).

Currently, over 70% of CNMs and CMs have earned amaster’s degree or higher, many while completing theircompetency-based midwifery education at a university orcollege. Starting in June 1999, the ACNM DOA re-quires that all accredited programs grant no less than abaccalaureate degree on completion, or alternatively,require a bachelor’s degree upon entrance. As of July1999, 45 programs were DOA-accredited/preaccred-ited. Of these, the majority require a master’s degreeeither prior to or concurrent with the completion of theprogram; of those who do not have this requirement, allbut one offer an optional mechanism for master’s com-pletion. See Appendix. Even though ACNM has longpromoted the concept of competency-based educationand does not support requirements for a master’s degreefor licensure or membership, the majority of programsrecognize the comprehensive and time-intensive natureof midwifery education and have expanded the comple-tion requirements enough to award a master’s degree.

As of January 1996, the ACC, which is responsiblefor the national certification examination, began to issuetime-limited certificates and established a CertificationMaintenance Program. These new and more rigorousrequirements to demonstrate continuing competencywill help address recent demands from consumers andregulators to design a better certification system toprotect consumers from unsafe practitioners in anyhealth profession (6,7). In addition, the ACNM hasbegun to develop a benchmarking process for midwives.This is possibly the first group of professionals to utilizea national benchmarking process to assist individuals toevaluate their outcomes of care in relation to their peersthroughout the country.

SCOPE AND STANDARDS OF PRACTICE

As defined by the ACNM, midwifery is the independentmanagement of women’s health care, with a particularfocus on pregnancy, childbirth, the post-partum period,care of the newborn, and the family planning andgynecologic needs of women (8). Following a primarycare model, midwifery practice includes the knowledge,skills, judgment, authority, and accountability required tomanage patient care. In most situations, midwives areable to assume complete responsibility for managementof patient care. In other situations, pre-established prac-tice guidelines or collaborative management arrange-ments permit the midwife to implement a plan of care orto perform certain procedures. When the needs of thepatient go beyond the scope of an individual midwife’spractice, referral to another provider, most often aphysician, is the norm.

Midwives practice within a health care system thatprovides for consultation, collaborative management, orreferral as indicated by the health status of the client (9).Midwives are expected to practice in accord with theStandards for the Practice of Nurse-Midwifery asdefined by the ACNM (ACNM, 1992, currently underrevision). Any new or advanced skills are expected to becongruent with the ACNM Philosophy and “Guidelinesfor the Incorporation of New Procedures into Nurse-Midwifery Practice” (10).

CURRENT LEGAL AND REGULATORY STATUS

All 50 states, the District of Columbia and the five U.S.territories regulate nurse-midwives and recognize theCNM credential, which has been earned by over 7,000individuals. In addition, CMs are authorized to practice inRhode Island and New York. In 1995, the first educationprogram for CMs to be recognized by the ACNM DOAwas established in New York and, as of May 1999, 11individuals have earned the CM credential.

While midwifery regulatory mechanisms vary fromstate to state, there is relative uniformity in terms ofscope of practice, qualifications for practice, and ar-rangements for medical consultation and referral (11).Even though some people still associate midwifery prac-tice exclusively with maternity care and family planning,nurse-midwives have a long history of caring for womenoutside of the maternity cycle and of providing primaryhealth care for women (12,13); this expanded scope ofpractice is recognized in all jurisdictions. In addition, 47jurisdictions, including the District of Columbia andAmerican Samoa, recognize prescribing appropriatedrugs and treatments as an essential component ofmidwifery practice for a CNM; in all but seven of thesejurisdictions, the law also allows a CNM to prescribecontrolled substances (14). Because the CM is a new


midwifery credential, New York is the only state, thusfar, in which CMs have prescriptive authority.

MEASUREMENTS OF SAFETY AND SUCCESS

The success of the ACNM standards can be measured inseveral ways. Currently, 45 nurse-midwifery educationprograms and one basic midwifery education programare accredited by the ACNM DOA. See Appendix.These programs are found in 26 states plus the Districtof Columbia. One of the newest programs is at theUniversity of Puerto Rico, where graduates will earn amaster’s degree in public health. This new program willsignificantly increase the number of midwives who speakSpanish and, as a result, the ACC certification examina-tion has been translated into Spanish. The number offormally educated nurse-midwives increased from 500 inthe mid-1960s, to 4,000 by the early 1980s, and over7,000 in 1999 (15). The demand for midwifery carecontinues to grow and, since 1994, close to 500 nurse-midwives have been certified annually. From 1989 (thefirst year for which there are national data on the numberof births attended by CNMs) to 1997, the percent ofCNM-attended births in the United States increased from3.3% to 6.7%. In 1997, more than 5,500 practicingnurse-midwives attended just over 250,000 births annu-ally (16,17), and in 1991, CNMs provided care towomen and families in over 5 million ambulatory visits(12).

In 1997, CNMs attended over 10% of all births ineach of seven states: Alaska, Florida, Maine, Massachu-setts, New Mexico, New York, and Oregon, (16,17). Bycontrast, CNMs attended fewer than 2.5% of all births in10 states. While the vast majority of births attended byCNMs or CMs occur in hospitals (96%), midwives alsoprovide services to low-risk women who choose to givebirth in a freestanding birth center (2.5%) or in the home(1%) (16). The majority of midwife-attended home birthsare, in fact, attended by midwives other than CNMs andCMs (18). In more than 2,500 hospitals or clinicsthroughout the country, CNMs and CMs have estab-lished collaborative relationships with obstetrician/gyne-cologists, family physicians, and other professionals.

MONITORING OUTCOMES OF MIDWIFERY CARE

The validity of the criteria that underlie the standards ofeducation and practice for a profession must, ultimately,be tested by measuring the impact on the populationserved. Since 1928, when Mary Breckenridge first pub-lished data from the FNS (3,19) and later, when theMetropolitan Life Insurance Company published infor-mation about the excellent outcomes of the care pro-vided by nurse-midwives at FNS (including major reduc-tions in both maternal and infant mortality) (20), nurse-

midwifery in the United States has been studiedextensively. As summarized in the book Midwifery andChildbirth in America (21), over 50 papers have beenpublished that specifically document the outcomes ofcare provided by U.S. nurse-midwives. Researchers havereported on site-specific or birth certificate outcome data(22–24), provided comparisons between medical careand midwifery care (25–32), studied the degree to whichwomen are satisfied with midwifery care (33), and de-scribed the cooperative relationship between midwivesand physicians (34–37). Some authors have docu-mented the impact of midwifery care on cost-effective-ness and the utilization of resources (34–47). Addition-ally, when provided to matched populations, midwiferyand medical care have been found to be comparable. Infact, there is consistent documentation that even whencontrolling for high-risk factors, patients of nurse-mid-wives have lower cesarean section rates and fewer lowbirth weight babies (48).

MIDWIVES AND MANAGED CARE

After learning about midwifery education, practice, andoutcomes, most students of managed care would agreethat midwifery and managed care are well-suited to oneanother. It seems logical that systems built on the tenetsof providing cost-effective, high quality care that empha-sizes health promotion, disease prevention, and patientsatisfaction would employ professionals who share sim-ilar values. The fact that midwives are willing to limit theuse of interventions such as ultrasound, episiotomies,and continuous electronic fetal monitoring to thosesituations where they have been proven to be effective,could make a significant contribution to controlling costs.In fact, early staff-model health maintenance organiza-tions (HMOs) in the western United States, such asKaiser Permanente and the Group Health Cooperativeof Puget Sound, have been utilizing CNM-MD teams toprovide women’s health care for many years. The con-tributions of nurse-midwives to the mission of KaiserPermanente are documented in a study which found thatthe use of CNMs reduced inpatient and payroll costswhile providing care equivalent to that provided byphysicians, that the working relationship between phy-sicians and CNMs was positive, and that the majority ofwomen surveyed preferred to have their care providedby CNMs (39).

In spite of the mounting data that document the highquality, accessibility, and cost-effectiveness of nurse-midwifery care, the widespread adoption of a managedcare model for delivering health care is getting mixedreviews from midwives. Recently, ACNM staff con-ducted an electronic survey in which CNMs and CMswere asked to describe the most common problemsfaced by women who seek family planning services,


maternity care, and perimenopausal care. Virtually allrespondents reported that lack of, or confusion about,coverage, especially under Medicaid managed care, hasbecome a significant problem. All across the country thecomplaints were the same: women are suffering becausethey cannot get the care they need. There is also asignificant amount of fear among midwives about theresponse of the medical community as managed carebecomes more widespread. For many years, some physi-cians have been openly resistant to the practice of mid-wifery and have engaged in activities that have made it verydifficult for midwives to practice their profession. Require-ments such as one must be an employee of a physician,must have a physician present in the room, cannot bereimbursed directly for services, can only accept patientswho have been screened by a physician, or cannot use thetitle “doctor” if you have earned a PhD but not an MD,degrade the profession, keep income artificially low, andlimit access to midwifery care. Recent events have in-creased competition between physicians and, in somestates, there appears to be an increase in the number ofattempts to discredit the midwifery profession and to passlaws that limit opportunities to practice.

It is well known that there are many new individualsinvolved in decision-making about access to and contentof health care. The health care industry has taken on amuch more business-like approach. One change that hasfar-reaching consequences is that the individual is nolonger purchasing health care directly from a provider.Five years ago, under privately financed health care, themajority of consumers ultimately controlled where theirhealth care dollars were spent. Even though an insur-ance company may have been paid by an employer orgovernment agency, most consumers could still selectthe physician or other care provider of their choice.After years of work under the fee-for-service plans,nurse-midwives had convinced most indemnity insurancecompanies to reimburse for nurse-midwifery care, andthe number of women receiving care from nurse-mid-wives was growing. But, under managed care, it hasbecome increasingly difficult for the recipient of healthcare to influence the system. Often, the only time choiceenters the equation is when the employer chooses acompany to provide health benefits to its employees.Since most employers do not offer more than one plan,if employees are unhappy with any aspect of their plan,such as lack of access to midwifery care, they cannottake their money and shop elsewhere.

In addition to the dramatic loss in patient choice ofcare provider, the rapidity with which hospitals, otherhealth care agencies (including managed care organi-zations), and insurance companies are changing own-ership has created chaos for patients, doctors, andmidwives. Health care association newsletters arefilled with stories about the challenges inherent in the

current marketplace. The variety of business relation-ships that have been proposed, incorporated, anddissolved in order to respond to the market is a majordistraction for those who only want to provide care towomen and families. There is a great deal of uncer-tainty about how to make a living as a health careprofessional and a sense of panic that has torn apartlong-standing working relationships. Some physiciansand midwives who worked for years in tertiary caresettings with large populations of women who wereMedicaid-eligible have been laid off. Private corpora-tions have been forced to merge in order to competefor managed care contracts and these mergers, all toooften, bring downsizing of staff. Health care profes-sionals also lament that they are being judged by thenumber of clients they see, rather than the content oroutcomes of the care they provide. ACNM membersreport that it is increasingly difficult to find time topersonalize patient care. Some fear that the midwiferymodel of care, which requires time to be with women,will be lost forever in a managed care model ofpractice. The demand to see more clients has alsobeen blamed for decreasing the ability of professionalsto follow-up on complicated cases, educate students,participate in professional development, and conductresearch. Some, like the American Nurses Associa-tion, fear that inadequately prepared and unlicensedproviders are replacing licensed professionals andpredict an increase in morbidity and mortality as aresult. It certainly should be a concern to all that thenumber of uninsured people continues to rise in thistime of relative prosperity and that there seem to befewer systems designed to provide care to those whohave no insurance.

Conversely, many midwives report that they havemaintained a prominent position in the managed caremarketplace. The number of births attended by CNMshas continued to rise during the chaos of this transitionand some midwives report a great deal of acceptance insystems faced with a high volume of patients and byyounger physicians, who seem more likely to recognizemajor benefits from working with midwives (49). In somecases, the midwives have been welcomed in communityhospitals that have negotiated Medicaid managed carecontracts. Some employers have discovered that theyhad underestimated the contributions of a midwife,particularly in helping to provide 24-hour “on-call” cov-erage of labor units, and ultimately rehired midwives.Other CNMs have launched lucrative new businesses inpartnership with other nurse practitioners and physi-cians. A multidisciplinary group of providers who canaccept capitated funds and share risk seems to be quitecompetitive at this point in time (50).


WORK ON STATE AND NATIONAL POLICY

Since the 1980s, the ACNM has been very successful inlobbying for policies that provide access to, and reim-bursement for, midwifery care. According to federalMedicaid laws, states are required to cover all nurse-midwifery services allowed under state law, regardless ofwhere they are performed (51). But, during the Medicaidtransition from fee-for-service to managed care, somestates have been slow to include access to nurse-mid-wifery care in their managed care contracts. Eventhough the number of noncompliant states has de-creased by more than one-half in 2 years, 11 jurisdic-tions (Colorado, Delaware, Illinois, Massachusetts, Mis-sissippi, Oregon, Rhode Island, Tennessee, Vermont,Virginia, and the District of Columbia) are still notcontracting for CNM services with Medicaid MCOs (52).Since 1988, Medicare has also covered services ren-dered by CNMs. Unfortunately, in 1988 the Medicarereimbursement rate for nurse-midwives was set at 65%of the physician fee schedule. Even though CNMs do notprovide care to a large number of Medicare beneficiaries,Medicare is often the trend setter for other policies andthe government has generated evidence that this reim-bursement rate is not consistent with expenses incurredto provide the service (51). Still, in-spite of multipleattempts, the ACNM has not been able to change thispolicy. In 1999, nurse-midwives were recognized asprimary care providers by Medicaid, Medicare, and thePresident’s Advisory Commission on Consumer Protec-tion and Quality Assurance. State policy-makers havealso recognized the value of midwifery care and 37jurisdictions mandate private insurance reimbursementfor nurse-midwifery services (14).

As a result of these inconsistent policies, the ACNMhas been very concerned about the impact of managedcare on women and on access to midwifery care. Besidesmonitoring laws and regulations and lobbying for im-proved legislation, the organization has made a con-certed effort to educate members about the business ofhealth care. The ACNM has created a Business TaskForce and published two handbooks on managed care.Recent publications have addressed marketing and pub-lic relations along with detailed information on billingand coding. The work of the organization has alsofocused on federal and state policies that support con-sumer protections under managed care, expand accessto full scope midwifery care for all consumers, increasethe pool of primary care providers for underservedpopulations, and preserve antitrust remedies in thehealth care arena.

Because the ability to work as a midwife is ultimatelycontrolled by state licensure laws and regulations, theACNM has also worked to ensure that appropriate nationalstandards for midwifery education, certification, and prac-

tice are adopted in every jurisdiction. Seventy-two ACNMchapters (at least one in each state) receive regular supportfrom the national organization. In 1997, ACNM created astaff position for a policy analyst to focus exclusively onactivities at the state level. It was during this time that thefederal government began to implement policies thatplaced more health care decision-making with the states.This devolution of power, accompanied by efforts to re-duce spending in Medicare and Medicaid, and the move tomanaged care, significantly increased the need for mid-wives who could monitor and influence state policies.Through a variety of communication mechanisms, ACNMis able to provide access to information and advice for itsmembers who wish to influence decisions that impactwomen’s health care.

Midwives who seek clinical privileges in hospitals andbirth centers and reimbursement from managed careorganizations are usually required to carry malpracticeinsurance. Based on its standard-setting activities,ACNM has been able to ensure that a professionalliability policy is available to qualified CNMs and CMs inevery state. While a number of different policies areavailable in selected states, the policy endorsed byACNM is the only one that offers coverage in everystate. The ACNM-endorsed policy has incorporated anumber of risk management activities that are imple-mented in partnership with the national organization.

Finally, the organization has provided regular andrepeated comment to the Joint Commission on Accred-itation of Healthcare Organizations (JCAHO). TheJCAHO medical staff standards have a significant impacton the ability of midwives to obtain clinical privileges ata hospital. Recently, JCAHO expanded its mandate toinclude birth centers and MCOs. Unfortunately, severalJCAHO standards relating to who can conduct a historyand physical exam, who can admit a woman to labor anddelivery, and who has access to due process shouldaccusations of inappropriate or unsafe practice be raisedare problems for midwives.

STATE AND FEDERAL PARTNERSHIPS

Nurse-midwives have a long-standing record of advocat-ing for public policies that improve access to quality carefor all women. As a result, the ACNM has recentlyheightened its endeavors to partner with federal andstate agencies in an effort to accomplish important goalsfor women and their families who are struggling to“survive” in a managed care environment.

In 1997, the ACNM and the Maternal and ChildHealth (MCH) Bureau, Human Resources and ServicesAdministration, U.S. Department of Health and HumanServices, entered into a three-year “providers partner-ship.” The goals of the ACNM–MCH partnership are to:1) establish effective and sustainable dialogue among


maternal and child health public and private providerswith a focus on leadership development, collaborativeefforts, and problem-solving at the local and state level;2) utilize a variety of communication linkages to transferinformation and knowledge gained to and from theMCH; 3) utilize data to describe the impact of changes inthe health care environment on CNMs and their pa-tients; and 4) strengthen the ability of private providersto respond to these changes. The ACNM–MCH Provid-ers Partnership recently surveyed 6,365 CNMs andcollected data on their practice settings, characteristics oftheir clients, impacts of changes in health care organi-zation and financing on their practices, impacts of thesechanges on their clients, and their relationships withstate maternal and child health programs. Findings fromthis study will be available in late 1999 and should helpenlighten consumers and policy-makers about some ofthe risks and benefits of managed care.

The Providers Partnership will also fund state widemeetings between public and private providers of healthcare for pregnant women. These meetings will provide theopportunity for midwives to develop relationships withtheir state maternal and child health and Medicaid pro-grams, to share concerns about the impact of changes inthe financing and delivery of health care services onwomen, and to work with other providers to identifysolutions. The meetings will involve representatives from avariety of stakeholders and include the voice of consumers.

THE QUEST FOR DATA

There are few data to document the impact of managedcare on the population as a whole, much less vulnerablepopulations in need of maternity or gynecologic services.Whether one is concerned about consumers or a groupof health care professionals, it is hard to determine if themovement towards managed care is good or bad.

Historically, the majority of women served by CNMshave been considered more vulnerable to poor preg-nancy outcomes than normal, based on their socioeco-nomic status, age, ethnicity, place of residence, andeducation (12,13,53). Of these vulnerable women, thosewho are pregnant will be impacted relatively early bymajor changes in the accessibility or content of prenatalcare. Rather than wait for a body of research to emergethat definitively measures the impact of managed care onthe health of the population, some policy-makers mightopt to view midwives as “canaries in the mineshaft” inregards to the effects of managed care. As providers whohave traditionally listened to women, midwives may beable to offer early warning signs about the health ofwomen when dramatic attempts are being made todecrease the cost of providing health care in the UnitedStates. The ACNM–MCH Providers Partnership surveyresults may offer precisely this kind of warning.

PRESERVATION OF MIDWIFERY IN A MANAGEDCARE ENVIRONMENT

Over 70 years ago, the profession of nurse-midwiferybegan in this country, with its roots in the care of popula-tions who were underserved and uninsured. Despite nu-merous advances and the support of a national organiza-tion, there is mounting anecdotal evidence from midwivesthat managed care may be having a negative impact on thewomen and families they serve. In addition, if womencannot use their health insurance policies to pay for mid-wifery care, survival in a managed care environment will bevery difficult for midwives. The possibility that managedcare will negate the impact of many hard-won policydecisions is a concern of the leadership and member-ship of ACNM. The ACNM response to managed carehas focused primarily on educating members to mar-ket midwifery to managed care organizations, respondappropriately to the new business realities, and pre-serve the philosophy of midwifery care within theevolving system. Simultaneously, the organization haslaunched a national marketing campaign, expandedits efforts to support state initiatives, promoted mid-wifery research, worked collaboratively with otherorganizations to promote improved access to qualitywomen’s health care, expanded its quality assurancemechanisms, and promoted policies that maintain afair market share for midwives.

Several of the recommendations put forth by the PewHealth Professions Commission and the University ofCalifornia, San Francisco (UCSF) Center for the HealthProfessions in The Future of Midwifery (50,54) have beenaccomplished over the past few decades, or are well ontheir way to being accomplished in the near future. This isa profession that has nationally recognized standards foreducation, certification, and practice, a high degree ofconsumer acceptance, a demonstrated ability to workcollaboratively with physicians and policy-makers, and datato support the appropriateness of its standard-setting activ-ities. Some of the recommendations from the Pew/UCSFreport (50,54), especially those relating to research, edu-cation, and policy, will require funding and expertise that iscurrently beyond the means of the organization. Since thegovernment plays a significant role in assuring that thepopulation receives medical care from qualified physicians,the ACNM would welcome a similar commitment to assurethat the midwifery model of care is embraced by, andincorporated into, the health care system and made avail-able to all women.

The author wishes to acknowledge the contributions of Lisa Paine, CNM,DrPH, FACNM, Chair, Department of Maternal and Child Health, BostonUniversity School of Public Health. As an expert in public health policyand Chair of the UCSF Taskforce on Midwifery, she provided invaluableeditorial assistance in the preparation of the final manuscript.


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APPENDIX

ACNM ACCREDITED/PREACCREDITED NURSE-MIDWIFERY AND MIDWIFERY EDUCATION PROGRAMS

Certificate Programs

Baystate Medical Center *06†Frontier School of Midwifery and Family Nursing*05†§■

Community-Based Nurse-Midwifery Education Program(CNEP)

Institute of Midwifery, Women and Health@†§■Parkland School of Nurse-Midwifery *04†§University of Medicine and Dentistry of New Jersey *02†§

Graduate Programs

Baylor College of Medicine (MS) *02†Boston University (MPH) *06†Case Western Reserve University (MSN

or ND) *00†Charles R. Drew University of Medicine

and Science (MS) *03†§Columbia University (MS) *04†§¶VEast Carolina University (MSN)

*06†§¶V■Emory University (MSN or MSN/MPH)

*05†¶MGeorgetown University (MS) *03†§¶Marquette University (MSN) *01†¶Medical University of South Carolina

(MSN) *03†§¶VMNew York University (MA) *03†¶VMfOhio State University (MS)*00†¶VOregon Health Sciences University (MS)

*03†¶San Diego State University/University

of California, San Diego (MS) *03†

Shenandoah University (MSN)@†State University of New York Health

Science Center at Brooklyn (MS)*04†‡§¶●■

State University of New York at StonyBrook (MS) *00†§¶Vf

University of California, Los Angeles(MSN) *03†§M

University of California, San Francisco/San Francisco General Hospital (MS)*02†§¶●Vf

University of California, San Francisco/University of California, San Diego(MS) *04†¶

University of Cincinnati (MSN) *00†University of Colorado (MS) *06†§¶VMmUniversity of Florida (MSN or MN)

*03†¶MfUniversity of Illinois at Chicago (MS or

PhD) *03†¶mUniversity of Maryland (MS)@†

University of Miami (MSN) *04†University of Michigan (MS/PhD) *06†University of Minnesota (MS/PhD)

*02†§¶VfUniversity of Missouri at Columbia (MS)

*03†¶fUniversity of New Mexico (MSN) *07†¶University of Pennsylvania (MSN)

*02†¶VfUniversity of Puerto Rico (MPH)@†¶●University of Rhode Island (MSN) *01†¶University of Southern California

(MSN)@†§¶VfUniversity of Texas at El Paso/Texas

Tech University (MSN) *00†§¶University of Texas Medical Branch at

Galveston (MSN) *01†¶University of Utah (MS) *06†§¶fUniversity of Washington (MN) *01†§¶Vanderbilt University (MSN) *02†¶MYale University (MSN) *02†V

KEY:@ 5 Preaccreditation status; initial accreditation review within six months after graduation of first class.* 5 Accreditation status followed by year for next scheduled accreditation review.† 5 Nurse-midwifery program.‡ 5 Midwifery program.The following options may be available at the education program. Please contact the education program directly for more information about theoption(s).§ 5 Master’s completion option.¶ 5 Post-master’s certificate option.● 5 Certificate option.V 5 BA/BS to RN/CNM-graduate program option.M 5 Diploma or associate degree (AD) RN to CNM-graduate program option.f 5 Distance education option.

CURRENT AS OF JULY 1999


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PRESERVING MIDWIFERY PRACTICE IN A MANAGED CARE ENVIRONMENT