Midwifery clinical practice and education has changed significantly since Mary Breckinridge first introduced nurse-midwives to the United States in 1925. This article discusses current challenges in midwifery clinical practice and education and proposes possible solutions. Midwifery clinical challenges include restrictive legislation and business-related barriers, including but not limited to physician supervision restrictions, prescriptive authority, out-of-hospital birth legislation, and third party reimbursement. Educational challenges highlighted include the current healthcare climate’s influence on midwifery education, the contribution of clinical sites and preceptors, and the benefits of midwifery education.
Key words: midwife, nurse-midwife, midwifery clinical practice, midwifery education, Certified Nurse-Midwife, Certified Midwife, birth, nurses, nursing
In the United States, the first modern day nurse-midwives were British-educated women brought to this country by Mary Breckinridge in 1925. Midwifery is an ancient profession still actively practiced throughout the world. In the United States, the first modern day nurse-midwives were British-educated women brought to this country by Mary Breckinridge in 1925. Their focus was to provide healthcare in the remote mountains of rural Kentucky (King et. al, 2013) for an organization that became known as the Frontier Nursing Service (FNS). The same year, the first school specifically established to educate nurse-midwives was established in New York City, the Manhattan Midwifery School.
The current maternal-infant healthcare climate in the US is widely acknowledged to be in great need of modification... From these early beginnings, the profession has grown to include 13,607 Certified Nurse-Midwives (CNMs), 87 Certified Midwives (CMs) (AMCB,2014b) and 39 CNM/CM education programs (ACNM,2012b). The current maternal-infant healthcare climate in the US is widely acknowledged to be in great need of modification with midwives being seen as key in returning birth care to a more normal, physiologic state that is woman-centered. Consequently, more needs to be done to realize the goal of every woman and family having access to midwifery care. Yet legislative, business, and education challenges to midwifery practice remain. Reviewing all the clinical practice and educational challenges is not within the scope or space limitations of this paper; thus, select current clinical practice and educational challenges as well as possible solutions are discussed.
Background of CNM Practice
CNMs are registered nurses educated in the two disciplines of midwifery and nursing who attend graduate education programs (usually in schools/colleges of nursing) approved by the Accreditation Commission for Midwifery Education (ACME). Graduates must pass a national certification exam administered by the American Midwifery Certification Board (AMCB); they are licensed and have prescriptive authority in every state (ACNM, 2012c). The American College of Nurse-Midwives (ACNM) values graduate education but does not support only the Doctor of Nursing Practice (DNP) as a requirement for entry into practice (ACNM, 2012d). CMs are educated in the discipline of midwifery and earn graduate degrees from ACME accredited midwifery education programs after completing health and science education requirements (ACNM, 2012c). CM education programs base their curricula on the same ACNM documents as CNM programs and their graduates sit for the same certification exam (ACNM, 2012c). CMs are currently licensed in five states: Delaware, Missouri, New York, New Jersey, and Rhode Island.
CNMs are registered nurses educated in the two disciplines of midwifery and nursing...they are licensed and have prescriptive authority in every state. Successful completion of the ACME accredited education programs demonstrates that CNM/CMs have met the ACNM Core Competencies for Basic Midwifery Practice (ACNM, 2012e). Midwives practice in accordance with the ACNM Standards for the Practice of Midwifery (ACNM, 2011a) which are consistent with or exceed the global competencies and standards for midwifery practice as defined by the International Confederation of Midwives (ACNM, 2012c). To maintain the designation of CNM or CM, midwives must recertify every five years through AMCB and meet designated continuing education requirements (ACNM, 2012c). CNM/CMs represent the majority of US midwives and, in 2011, attended 92.2% of midwife-attended births (ACNM, 2013a). Other midwife providers include Certified Professional Midwives (CPM), Direct Entry Midwives (DEM) and lay midwives. In this paper, the terms “midwives” and “midwifery” are used to signify CNM/CMs and their clinical practice.
A distinctive feature of midwifery care is its strong emphasis on developing a partnership with women and families... Midwives are designated primary care providers, and their care includes primary; gynecologic and family planning; preconception; pregnancy, childbirth and the postpartum period; normal newborn during the first 28 days of life; and treatment of male partners for sexually transmitted infections (ACNM, 2012c). Care settings include outpatient clinics, private offices, community and public health centers, birth centers, homes, hospitals, and more. Midwifery care also includes health promotion, disease prevision, and individualized wellness education and counseling (ACNM, 2012c). Midwives conduct physical examinations; prescribe medications including controlled substances and contraceptive methods; admit, manage and discharge patients (in hospitals and birth centers); order and interpret laboratory and diagnostic tests; and order the use of medical devices (ACNM, 2012c). A distinctive feature of midwifery care is its strong emphasis on developing a partnership with women and families and providing care with respect for their involvement and active participation in healthcare decision making.
Births attended by CNM/CMs have risen every year since 1989... In the US, the profession and practice of modern day midwifery has evolved significantly since introduced by Mary Breckinridge in 1925. Births attended by CNM/CMs have risen every year since 1989 (the first year statistics were available) (ACNM, 2013a). In 2011, 7.6% of all US hospital births and 30.2% of out-of-hospital births were attended by CNM/CMs (ACNM, 2013a). Midwifery care results in lower costs due to fewer unnecessary, invasive and expensive interventions and is associated with lower rates of cesarean birth, labor induction, and augmentation; less use of regional anesthesia; significant reduction in the incidence of third and fourth degree perineal tears; and higher rates of breastfeeding (ACNM, 2012a). Rising cesarean birth rates have been an ongoing challenge with 1 in 3 women giving birth by cesarean section in 2011 for a rate of 32.4%, (Martin, Hamilton, Ventura, Osterman, & Mathews, 2013). The continuing dramatic rise represents an ongoing “dehumanization and medicalization of birth,” despite clear evidence of the harm that occurs to both mothers and babies (Wagner, 2001). While various reasons such as changing demographics, medical legal climate, and resident training have been considered to explain the rise in Cesarean birth rates, a review of the primary cesarean section rates by states suggest a variety of medical practices may strongly influence the method of birth (Osterman, & Martin, 2013). Campaigns by the March of Dimes and the American Congress of Obstetricians and Gynecologists aimed at eliminating non-medically indicated birth before 39 weeks of ...research has shown that midwifery care is of high-quality and comparable to or better than care provided by obstetrician/gynecologists. gestation have resulted in a reduction in cesarean birth at 38 weeks but an increase in cesarean birth at 39 weeks (Osterman, & Martin, 2014). The shift in practice to delay induction of labor until after 39 weeks is one area that demonstrates medicalization of birth which results in increased cesarean birth. In a recent Cochrane Review, births attended by CNM/CMs consistently demonstrated safety, less use of interventions, and fewer cesarean births (Sandall, Soltani, Gates, Shennan, & Devane, 2013). The three major midwifery organizations in the United States have joined together to promote a greater awareness and respect for normal birth. Recognizing that the use of interventions in the birth process is excessive they have published a resource for women called, “Normal, Healthy Childbirth for Women & Families: What You Need to Know.” Its purpose is to inform women in their decisions surrounding medical interventions during birth (ACNM, 2014). In general, research has shown that midwifery care is of high-quality and comparable to or better than care provided by obstetrician/gynecologists (ACNM, 2012a).
Clinical Midwifery Practice Challenges
Challenges and barriers to CNM/CM clinical practice generally fall into one of two categories: those created by restrictive state laws and regulations and those that, although they may have a regulatory component, can be considered related to the business of midwifery. This section of the paper describes major regulatory and business midwifery challenges.
Both the legislative authority granted to CNM/CMs to practice independently and where they practice varies considerably state to state. According to data compiled by ACNM on State Legislation and Regulatory Guidance (ACNM, n.d.), midwives that are not nurse-midwives are illegal in 10 states, 12 states have no laws or regulations about non-nurse-midwives, and 2 states prohibit CNMs from doing home births
Three major regulatory challenges exist within many states: (1) the requirement for either physician supervision or a written collaborative agreement with a physician; (2) the requirement for physician supervision of prescriptive authority even in the presence of otherwise independent practice, as well as the extent to which prescriptive authority is granted (e.g., the ability to prescribe controlled substances); and (3) legislation governing midwives and out-of-hospital birth.
Collaborative agreements. These regulatory barriers hamper access to midwifery care in several ways. Hospital credentialing and/or admitting privileges may be denied if the CNM/CM cannot find a physician willing to sign a contractual agreement. Third-party reimbursement may also be denied without a contractual agreement, even if services clearly fall within the midwife’s scope of practice. The requirement for a formal contract with a physician also creates an economic disadvantage for CNM/CMs, either because it can restrict the number of midwives “allowed” to practice with a particular physician or because it creates a potential barrier to the development of practice in a particular area (ACNM, 2013b). In many instances, because of this supervisory requirement, midwives are not considered members of a “profession” and therefore CNM/CMs are unable to open their own practices as Professional Limited Liability Corporations (PLLC). Such laws may cause midwives to leave a restrictive state and move elsewhere to work, potentially decreasing access to midwifery care in that state.
Prescriptive authority.Prescriptive authority restrictions have long been problematic for midwives. Independent practice without the ability to independently prescribe is not independent practice. For example, in Michigan prescribing is the only midwife practice area requiring physician supervision or collaboration. However, the legal interpretation of this law has evolved into the opinion that if prescribing is supervised then perforce practice must be also. This barrier prevents the creation of practices especially where there is no physician willing to partner with a midwife. Unclear prescribing practices also results in patient – and pharmacy – confusion as to the prescriber and care provider, potentially resulting in a lack of provider accountability.
Legislated barriers require legislative change. While actively working for change is not an easy process, it can be particularly difficult for CNM/CMs due to their small numbers and demanding work schedules. Partnering with APRN groups has helped to move legislative change forward. Recently, in a number of states, APRNs and midwives have worked effectively together to remove, or at least lighten, restrictions. Currently, eighteen states have no restrictive regulatory requirement for written or formal physician involvement in midwifery practice, and more are working on this type of legislation (ACNM, n.d.). There may be other opportunities to partner with APRNs or other midwives to create legislation that removes barriers for all. Collaboration with grass roots organizations, for example, can be an incredibly powerful partnership.
The passage of the Affordable Care Act has also been key in bringing attention to the need for increased access to care as well as the importance of removing APRN practice restrictions. Several events in recent years have spurred an unprecedented opportunity to address regulatory challenges. Support from the nursing profession has been described in the National Council of State Boards of Nursing (2008) Consensus Model for APRN Regulation: Licensure, Accreditation, Certification & Education that defines the categories of APRNs (including CNMs). This groundbreaking document provides model regulatory language that clearly calls for autonomous and independent practice by APRNs without supervision. Another key document, the Institute of Medicine’s (2010) Future of Nursing: Leading Change, Advancing Health called for removal of barriers to APRN practice and for “the full extent of their education and training” (p.85). The passage of the Affordable Care Act has also been key in bringing attention to the need for increased access to care as well as the importance of removing APRN practice restrictions.
Midwifery and out-of-hospital birth. Between the professions of nursing and midwifery, an issue midwives uniquely face could be described as the “foot on each side of the regulatory fence.” Direct-entry midwives practice legally and are licensed separately in many states. A few states license all midwives under a Board of Midwifery, but most CNMs practice under the Board of Nursing, while a couple of states designate the Board of Medicine, and a few states issue licensing under joint regulation. ACNM considers the best model to be a separate Board of Midwifery (ACNM, 2011b). Those wishing to enter the profession of midwifery will have to thoughtfully evaluate each state’s needs and regulatory issues in considering where to practice.
Under the Affordable Care Act, Medicaid is required to reimburse for OHB services... Regulations are wide-ranging concerning out-of-hospital birth (OHB), defined as birth in free-standing birth centers or home birth. Birth center regulation exists in most states today; some are working on this legislation. States that do not regulate OHB face a considerable challenge. Under the Affordable Care Act, Medicaid is required to reimburse for OHB services; however, there is room for interpretation. Data compiled from 50 ACNM State Legislative and Regulatory Guidance sheets, reveals that a number of states actively discriminate against home birth and home birth care providers (ACNM, n.d.). A few states actively prohibit home birth care providers from practicing, whereas regulation in other states is either vague or absent entirely. Where there is no regulation, third-party reimbursement may be problematic. In addition, the frequent medical disparagement of those who choose to provide OHB services can result in erratic (at best) inter-provider communication and loss of continuity of care in the event of urgent transport to a medical facility.
Solutions to these pressing challenges include legalization, regulation, and professional recognition of all midwives... Solutions to these pressing challenges include legalization, regulation, and professional recognition of all midwives as well as all OHBs. Currently, this will require state-by-state legislative changes. The presence of safety measures such as adequate criteria for OHB candidates may be accomplished through education of providers. A “safety-net” system of seamless and respectful consultation, referral, and transfer between care providers in a timely manner also requires education and opportunities to build trusting relationships between OHB providers and in-hospital providers. A key strategy is working collaboratively with other professional and consumer groups toward solutions that enable midwives to provide care within the full scope of their practice. ACNM is politically active and has a long track record of success at the national level, both in the federal legislative arena and working with other national and international nursing, midwifery and medical organizations. ACNM lends support for state efforts as well and CNM/CMs are encouraged to take advantage of the organization’s abilities and resources if they wish to be involved in removing legislative barriers within their own states.
There are several barriers and challenges to the business of midwifery clinical practice that may result in decreased access to midwifery care by women and families.There are several barriers and challenges to the business of midwifery clinical practice that may result in decreased access to midwifery care by women and families. The major challenges presented here, along with possible solutions, include third party reimbursement, institutional rules and bylaws, liability, and the challenge of practicing true midwifery in the age of productivity demands and relative value unit (RVU) requirements.
Third party reimbursement. Midwives, indeed all APRNs, have struggled to become integrated into third party payors’ reimbursement plans. The first to include nurse-midwives was Medicare in the mid-1980s followed by Medicaid at the state level. Blue Cross Blue Shield (BCBS) and private insurers followed suit, although sporadically. Currently, about two-thirds of U.S. states mandate private insurer reimbursement to midwives, at least to some extent. A major legislative victory occurred recently when the low rate (65%) of physician reimbursement by Medicare was resolved. In many states, however, Medicaid and BCBS continue to reimburse less than the physician fee, limiting the ability of midwives to offer care (ACNM, n.d.).
The second part of the reimbursement hurdle is related to the legal scope of practice in states including how the legal definition may be interpreted. If the service performed is not within the limits of the state’s defined scope of midwifery practice, even if it is within the profession’s definition of midwifery basic or expanded scope of practice, then the subsequent requirement to bill under a physician’s name becomes a major practice barrier. If the midwife is not vigilant, the physician may receive credit for services performed by the midwife and be paid for those services instead of the midwife, resulting in lost revenue and a perception of decreased productivity by the midwife. These barriers can become so burdensome that midwifery services can no longer be offered to patients, who then must go elsewhere for the care needed – which the midwife was well able to perform.
Solutions to this reimbursement barrier frequently involve state level regulatory changes. The increase in reimbursement rate to 100% of the physician fee under Medicare may provide an opportunity to negotiate change in states where Medicaid is under-reimbursing. Creating access to corporate representatives in the form of practitioner/company liaison groups may also help get action within individual insurance companies. Michigan, for example, has had success through an APRN liaison with BCBS to work through issues such as adding reimbursement for midwife gynecologic services, as well as including midwives on the provider panels of auto company self-insured policies administered by BCBS.
Institutional rules and bylaws. The privileges of hospitals and medical systems may be regulated by the state, but more often institutions make their own rules in terms of who they allow to admit patients and which services the providers may perform. A few progressive states require that hospitals not discriminate against CNMs attaining hospital privileges. Conversely, several states limit admitting privileges to physicians. However, in most states there is no regulation concerning who may admit. Limiting CNM access can become a restraint of practice issue if individual hospitals create bylaws restricting admission privileges to physicians or require a collaborative agreement with a physician in order to admit clients in labor. Without creating new regulatory legislation mandating (or removing limits on) admitting privileges, this individual and local challenge will continue. The more midwives who are willing to challenge the status quo by applying for privileges and challenging restrictive bylaws, the sooner a change will be realized.
Liability. For a small practice, especially, one of the biggest out-of-pocket or overhead expenses is liability insurance. In many states, the insurance can be prohibitively expensive for all providing care during pregnancy and childbirth. This is why many small practices to choose to “go bare,” that is, not carry insurance. Some states offer non-economic damage caps but for many others there are no such limits. It is definitely a challenge to consider when starting a midwifery practice, and the liability issue drives many midwives out of smaller practices and into larger group practices or medical system models of care. The solution is not clear in our current litigious society. Damage caps and other limitations in law, such as tort reform, may be a place to start. However, some states have ruled these solutions as unconstitutional. And “going bare” is not always the answer; a lawsuit can be devastating to all concerned in that situation.
Vicarious liability, illustrated by a physician expressing “I don’t want to collaborate with a midwife because if I do, I become liable for his/her mistakes,” can create barriers in spite of lack of evidence that the situation really occurs. Where there is an employer-employee relationship, and the employer provides the malpractice policy, that liability is part of the contract. In a collaborative agreement between two independent partners each insured separately, there is no evidence of a vicarious liability relationship (Booth, 2007). There is an opportunity for education in this scenario, but midwives will need to be very clear, bringing data to the argument, when countering such concerns.
Productivity: Preserving the art in a numbers world. The Hallmarks of Midwifery (King et. al, 2013) from the ACNM Core Competencies for Basic Midwifery (ACNM, 2012e) clearly guides the principles and manner by which midwives combine the art and science of the profession. A distinctive characteristic of midwifery is the “art” or skill; another hallmark stems from the name itself: “with woman.” Midwives consider themselves partners with women to provide the care, treatment, and birth they desire. Ideally, they spend the necessary time, both in the office and at the birth site, to bring to fulfillment each family. Midwives guard against and watch for abnormalities and problems and take pride in judicious use of technology and the ability to combine technology with “the art of doing nothing well,” that is, the ability to keep hands off and allow nature to take its course. The challenge to midwifery care comes from our increasingly frenetic “numbers” world with emphasis on the quantity of clients seen versus quality of care provided. Viewing patients in terms of RVUs and amount of dollars generated is counter to the essence of midwifery. However, midwives along with other members of the healthcare team must balance philosophical approach against the need to generate income to survive.
There is no right or easy answer for this challenge. A private practice midwife may have more control over the amount of time spent with a client and how many clients at a time he/she accepts into the practice; this person’s income will be reflective of these preferences. However, midwives are finding that employers include productivity requirements in their contracts. The agreement may come in the form of a guaranteed base salary plus productivity bonus, or a group or individual-based productivity or RVU target beyond which bonuses may be expected, or even a purely productivity-based formula. The individual challenge to each practice and each midwife is to generate the income needed to survive and thrive while holding to core values of midwifery and nursing: woman- and family-centered care, empowerment of women as partners in healthcare, health promotion, disease prevention, and health education.
Current Midwifery Education Challenges
ACNM envisions that by 2015 CNM/CMs will attend 20% of US births; a corresponding goal is 1000 midwives newly-certified each year by AMCB (ACNM, 2012b). The numbers of CNM/CMs continue to rise each year – 539 were newly-certified in 2013, a 3.4% increase from 2012 (AMCB, 2014a) – but their ranks are growing more slowly than may be needed by 2015. However, with demand for CNM/CM services increasing due to consumer interest and mandated access to healthcare, the goal of 1000 certified midwives per year may yet be attained.
Midwifery education occurs within the context of our current health system and the influence of this climate on education deserves close scrutiny. Midwifery education occurs within the context of our current health system and the influence of this climate on education deserves close scrutiny. Surprising to many people, 95.2% of births (ACNM, 2013a) attended by CNM/CMs occur in a hospital setting, a location often dominated by the medical model. Hospital settings may make it difficult to practice the midwifery model of care (Fahy, Foureur, & Hastie, 2008) and have the potential to erode principles of evidence-based midwifery care such as watchful waiting, non-interference in normal processes and judicious use of interventions. Educating midwives in the hospital may also limit the numbers of experiences students have with normal, physiologic birth practices. Faculty and preceptors are called upon to creatively support normal physiologic birth within that setting and role model the philosophy of “being with women” in a compassionate way. Effects of the medicalized approach inherent in the hospital setting can also be mitigated by midwives maintaining a clear focus on what works best for women.
Increasing educational experiences at free-standing birth centers and home births is a logical solution to the culture encountered in hospitals. Home and birth-center births, although still relatively rare, increased by approximately 40% from 2004 to 2010 (MacDorman, Declercq, & Mathews, 2013), hence increased opportunities for midwifery education may continue to grow. To further examine the challenges of increasing access to midwifery care through educating larger numbers of midwives, major challenges to this objective are grouped into three areas below: midwifery education programs, students, and clinical experience sites.
Midwifery education programs
There are currently 39 ACME-accredited CNM/CM midwifery education programs in the US. Two programs prepare CMs. Midwifery education occurs at the post-baccalaureate level and must be incorporated into programs that grant either the master’s or doctoral degree (ACNM, n.d.). The number of graduates increased in 2012 resulting in 489 students graduating from midwifery programs (15 doctoral degrees, 443 master’s degrees, 29 postgraduate certificates and 2 certificates) (ACNM, 2013c).
Many programs offer a “traditional” curriculum for BSN prepared RNs leading to a master’s or DNP degree. Four of the 39 midwifery programs offer a DNP only. Others offer an “accelerated” program whereby non-RN students with a bachelor’s degree in another area may complete their undergraduate nursing education as well as the graduate midwifery component. Certificate programs are also available for nurse practitioners who hold a graduate degree in nursing. The “accelerated” programs are in highest demand (ACNM, 2012b). In an ACNM Program Director Survey, one variable had a significant impact on enrollment trends: 88% of “accelerated” programs received 3.2 times more applicants than available spaces in contrast to “traditional” programs, 48% of which received more applicants than spaces (0.96 applicants for every space) (ACNM, 2012b). A possible solution, then, toward increasing numbers of CNM/CMs may be to offer an increased number of high demand “accelerated” programs.
The education of student midwives often begins with the admission of those who understand the work they embark on and the needs of women and families. In 2012, ACME-accredited midwifery programs noted a 26% increase in applications, receiving 1,625 qualified applications for an available 923 slots (ACNM, 2013c). The majority of nurse-midwifery students enter with a nursing labor and delivery background. Others bring experiences from other areas of nursing and healthcare as well as more diverse fields. A long-standing debate in midwifery education centers on the value of previous labor and delivery experience. Students without this experience may express idealized visions of birth but may be unable to clearly verbalize an understanding of the skills required for midwifery practice. These students can create unique challenges in acquiring the skills needed to meet current standards and use the technology. To be successful, students may need additional time to master basic skills and incorporate complex concepts into bedside care. In high volume, high-risk tertiary settings, these needs provide additional stressors for students, preceptors, staff, and faculty. However, it is may be less likely that these students will need to “unlearn” practices acquired in a medicalized birth setting.
On the other hand, experienced labor and delivery nurses usually enter midwifery with an existing knowledge base of maternity care, acquired in hospitals where continuous fetal monitoring, intravenous fluids, and epidural anesthesia are utilized (Declercq, Sakala, Corry, Applebaum, & Herrlich, 2013). These clinicians may have developed a medicalized birth approach and may have never cared for a laboring woman without an epidural unless the woman presented with an imminent birth. Use of epidural anesthesia by women in hospital birth settings increased from 22% in 1981 to 66% in 1997; current estimations are 80% in some hospitals (Block, 2007). This trend may serve to skew nurses’ views of birth and expectations of midwifery education and experience. The midwifery philosophy of care and the attitude of “watchful waiting for birth to unfold” may initially be a foreign and uncomfortable concept for experienced labor and delivery nurses, one to which they will need to become accustomed.
As another challenge to students in acquiring midwifery education, tuition for graduate degrees continues to rise while funding for financial aid decreases. Students are now required to accept more of the financial burden of higher education, potentially leaving less time for study and inviting more stress in the pursuit their goal. However, the good news is that midwifery students will see a positive return on their investment in professional and personal satisfaction as well as economic benefits. Midwifery students realize cost benefits primarily by receiving larger salaries and fringe benefits over the length of their midwifery careers compared to salaries they would have made as labor and delivery nurses. Fagerlund and Germano (2009) calculated the difference in salary plus fringe benefits (less taxes) in 2008 dollars between a CNM and a labor and delivery nurse: $1,048,106 over a 35-year career period. Accordingly, CNMs may potentially realize an 11.5% return on their education investment, a higher rate of return than placing the same money in a savings account or investing in other areas.
Clinical sites and preceptors
...growth of the midwifery profession depends on mutual collaboration between clinical sites and preceptors. Preceptors and clinical sites are major contributors to the midwifery education process. Their reciprocal bond with education programs is one of mutual dedication to the profession. Education programs rely on clinical sites and preceptors to provide clinical practice opportunities and clinical sites need to hire CNM/CMs to fill their positions. Preceptors serve as role models and teachers, imparting clinical expertise and setting safety limits (Lichtman et al., 2003). Unfortunately, the introduction of electronic health records and increased productivity demands make it more difficult for preceptors to accept, justify, and commit to sharing clinical experience due to increased demands on their time. Still, growth of the midwifery profession depends on mutual collaboration between clinical sites and preceptors.
As alternative learning experiences, midwifery students gain clinical expertise through simulation, role play and other methods, but obtaining direct patient contact in the company of an experienced preceptor who is appropriately licensed and certified is where the majority of learning takes place and is critical to the education process. Preceptors are primarily CNM/CMs but may be nurse practitioners, physicians, or other providers. Clinical experiences occur in outpatient as well as inpatient facilities. Midwifery education programs are competency-based; ACME requires that each student achieve a minimum number of direct patient contact clinical experiences ranging from preconception care, primary care (including common health problems, family planning and gynecology), antepartum, intrapartum, newborn, postpartum care, and breastfeeding support (ACME, 2013). This competency-based format differs from APRN programs that require students to accrue a specific number of clinical hours. In addition, students must meet the credit requirements of their midwifery programs.
In spite of challenges inherent to clinical education, midwifery education programs provide tangible and intangible benefits to practices. Students share their personal knowledge with preceptors and provide a fresh perspective. Midwifery preceptors experience professional growth that comes with serving as a faculty member, increased morale due to mentoring students and professional satisfaction in contributing to educating future midwives and increasing access to midwifery care. Moreover, Fagerlund and Germano (2009) reported that students provide quantifiable benefits to clinical practices through a decrease in recruitment costs for future midwives and through services provided. Services provided by midwifery students free up the clinical preceptor to complete other work for an average of 90 minutes per day for a total benefit to the practice of $5,180 per student per year. Fagerlund and Germano (2009) estimated a potential savings of $25,000 in recruitment and orientation savings to the practice when hiring one midwifery student per year. Given the many advantages of precepting a clinical midwifery student, including financial benefits, more clinical practices may want to consider partnering with a midwifery education program in educating future midwives.
The midwifery profession has faced and worked through many barriers over the past century, resulting in significant progress in providing access to care to women and families. Midwifery clinical practice and education challenges are multiple in today’s healthcare environment. One wonders what Mary Breckinridge would think of current healthcare and the changes to midwifery practice and education. The midwifery profession has faced and worked through many barriers over the past century, resulting in significant progress in providing access to care to women and families. However, midwives must continue to collectively and collaboratively work for change in our healthcare delivery system and specifically in the culture surrounding birth.
Within daily midwifery practice exists many opportunities to create the relationships needed to build a network of change. Great changes begin with small acts, for example creating a relationship with a legislator, educating a physician colleague, creating trust relationships with colleagues, locating and following up on a contact at an insurance corporation, and having the persistence to start and finish a bylaws change at a healthcare institution. To use a tried-but-true midwifery example, overcoming barriers is like birthing a baby; the gestation may be long but the birth rewarding, or put another way, labor may be difficult, prolonged, and painful but the end result is worth the work. Changes in midwifery, however, depend on a strong workforce. CNM/CMs graduates must be dedicated to the philosophy, poised to become change agents and aware of legislative and business issues as well as ready and willing to provide care in partnership with women across the lifespan. The preparation of midwifery students for the transition to being “with women” can be a beautiful and transformative experience for students, faculty, and preceptors alike, as well as the women being served. So as a dedicated workforce, let us take the barriers, create challenges from them, and watch the opportunities blossom!
Deborah S. Walker, DNSc, CNM, FACNM, FAAN
Deborah Walker is an Associate Professor at Wayne State University (WSU) College of Nursing in Detroit, MI. Dr. Walker received a BSN from Sonoma State University in Rohnert Park, CA, a MS (Nursing) from the University of Minnesota in Minneapolis and a Doctor of Nursing Science (DNSc) from the University of California in Los Angeles. She has been certified as a nurse-midwife since 1989 and actively involved in nurse-midwifery education for over 20 years. Dr. Walker has a long record of HRSA Division of Nursing funding that implemented increased educational innovation and diversity. She is the founding and current Director of WSU College of Nursing’s Nurse-Midwifery concentration that emphasizes culturally appropriate care of urban women to decrease health disparities. Since 2007, WSU nurse-midwifery graduates have launched new Detroit midwifery practices expanding the availability of care in an underserved area of extreme poverty. A recognized nurse-midwifery leader, her national roles include being twice elected Chair of the Directors of Midwifery Education, serving on the American College of Nurse-Midwives’ (ACNM) Board of Directors (2000-2003) and Fellow of the ACNM and the American Academy of Nursing.
Barbara Lannen, MSN, CNM
Barbara Lannen completed her master’s degree at the University of Illinois in Champaign, IL in 1991 and has been in full-scope nurse-midwifery practice in Detroit, Michigan for 22 years. She was the ACNM Southeastern Michigan chapter chair from 2001 through 2004, during which time she became actively engaged in the political challenges facing advanced nursing clinical practice in Michigan. She has continued to work with other advanced practice registered nurses (APRNs) in Michigan in order to bring about the changes needed to break down barriers to practice. In addition, she has been teaching in the Nurse-Midwifery & Women’s Health Nurse Practitioner concentrations at WSU College of Nursing since 2005, preparing new midwives and women’s health nurse practitioners (WHNPs) to face and overcome challenges.
Debra Rossie, MS, CNM
Debra Rossie graduated from the University of Michigan’s Nurse-Midwife Program in Ann Arbor, MI in 1996. She has served a variety of diverse populations of women in the Michigan communities of Bay City, Saginaw, and Metro Detroit. She established midwifery practices at two hospitals on Detroit’s East Side. In addition to private practice, for the past seven years she has held a faculty position in the Nurse-Midwifery and Women’s Health Nurse Practitioner program at Wayne State University College of Nursing in Detroit, MI. She was a team member of a Rotary International sponsored Vocational Training Team to assess maternal and infant mortality in East Timor. She has incorporated many complementary treatments into her practice and is a Reiki Master and has studied Aromatherapy and Acupressure for use in labor and birth. In 2012, she spent a year consulting with St. John Hospital and Medical Center in their Birthing Center as a Holistic Birth Consultant to align birth practices with the WHO Baby Friendly Initiative.
© 2014 OJIN: The Online Journal of Issues in Nursing
Article published May 31, 2014
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