pregnancy, to childbirth, through the postpartum period, as well as meeting women's gynecological needs during the menopausal and post-menopausal periods. Nurse midwives additionally may provide newborn care and will occasionally provide prenatal education, all as a part of their philosophy of family-centered care. A nurse midwife is a person trained in the two professions of nursing and midwifery as compared to a certified midwife (CM) who is trained in midwifery but not through the profession of nursing.
The certified nurse midwife (CNM) is an individual who has successfully completed an approved course of study in nurse midwifery and practices in compliance with the Standards for the Practice of Nurse Midwifery as defined by the American College of Nurse Midwives (ACNM). Midwives have attended births in America since colonial times, but the actual profession of nurse midwifery was not officially recognized in the United States until the early 1920s.
The nurse midwife provides women during pregnancy with appropriate supervision, care, and advice. During labor and the postpartum period, the nurse midwife performs vaginal deliveries and may care for the newborn while facilitating family involvement, particularly of fathers and siblings. Nurse midwives foster an environment that facilitates minimal intervention while continuously assessing for abnormal conditions in the mother and child that would necessitate medical assistance or emergency procedures.
Nurse midwives promote family-centered maternity care that incorporates counseling and education for the woman and the family. The occupation stresses the importance of antenatal education and preparation for parenthood. The nurse midwife acts as a kind of primary-care provider by providing the woman with family planning and a range of gynecological care.
Many of the clients that a nurse midwife cares for can be classified as "vulnerable" by one or more of the subsequent criteria: less than 16 years of age; level of education less than eight years; race and ethnicity other than white; and source of payment through public programs such as Medicaid, Medicare, and the Indian Health Service or free/self-pay. Women and infants seen by nurse midwives live disproportionately in areas where a higher than average number of people live below the poverty level.
The ACNM is the main professional organization in the Unites States representing CNMs and CMs. The group is the oldest women's health organization in the Unites States with roots back to the 1920s. ACNM conducts
research in midwifery practice; accredits midwifery schools; coordinates and administers continuing education programs; develops clinical practice standards of care; and works with state and federal agencies and members of Congress in promoting midwifery.
The practice of nurse midwifery is legal in all 50 states and the District of Columbia. Most nurse midwives function in a hospital or physician practice and attend deliveries in hospital settings. In 1997, 96% of nurse midwives delivered in hospitals, 2.4% delivered in separate birth centers and 1% delivered in a home setting.
Nurse midwives have various roles in the care facility, from providing solely intrapartal care to antepartal care to well-woman care to all of these combined. One of the more recent developments in hospital labor and delivery is the creation of birthing rooms that provide a more comfortable, home-like ambiance. Comfort features include showers or Jacuzzis, and beds that convert to birthing beds in which a woman can labor, deliver, and recover. Nurse midwives have been strong proponents of such advances and find them very useful in their practice.
Health maintenance organizations (HMOs) and managed care
Nurse midwives fit well into the model of managed care, which emphasizes cost-effective care focusing on prevention. They provide OB/GYN care as well as family planning. In 1992, Kaiser Permanente, a California-based HMO, reported that nurse midwives handled 70% of the low-risk obstetrical patients and had contributed to lowering the cesarean section rate to 12%. The national average for cesarean sections is 23.5%.
A great number of nurse midwives work in private practices of different sorts. Some practice in private OB/GYN practices with physicians, others in private nurse midwife only practices with physician consultation available, some in freestanding birth centers and a few perform home births. Private practices give nurse midwives greater
Freestanding birth centers offer the patient and her family a place to give birth that is a compromise between the hospital and home. In birthing centers, the nurse midwife tries to foster a home-like atmosphere as much as possible but still has the advantages of specialized equipment and proximity of emergency transportation.
Nurse midwives make a major contribution to caring for indigent and under-served populations in public health clinics—both independent clinics and those affiliated with a hospital. In these settings, nurse midwives attend to women that are susceptible to poorer than aver age outcomes of childbirth due to age, socioeconomic status, refugee status, and ethnic background.
Nurse midwives who assist in home births ensure the patient's and baby's safety while delivering personalized care and emotional support. A woman delivering in her own home experiences a familiar environment that is conducive to the woman retaining control of her birthing experience.
Before nurse midwifery was generally accepted in the United States, a large number of nurse midwives focused on the improvement of maternal-child health on a global level. A large number of international health organizations fund projects for nurse midwives in an effort to improve the health status of women and children throughout the world.
Education and training
The education of nurse midwives consists of a thorough foundation in the health sciences and extensive clinical preparation. Clinical training concentrates on the acquisition of knowledge, decision-making ability, and skills required to provide primary care and independent management of women and newborns. Students learn to function within a health care system where they can obtain medical consultation if necessary, where they can manage patients collaboratively and where they can refer when needed. The ACNM defines the scope of practice of a nurse midwife to include antepartum, intrapartum, postpartum, newborn, family planning, gynecology, and primary care.
The numbers of patient visits and experiences below represent suggested guidelines for nurse midwifery educational programs from the ACNM:
- 10 preconception care visits
- 15 new antepartum visits
- 70 return antepartum visits
- 20 labor management experiences
- 20 births
- 20 newborn assessments
- 10 breastfeeding support visits
- 20 postpartum visits (0-5 days)
- 15 postpartum visits (4-8 weeks)
- Primary care visits:
- 40 common health problems
- 20 family planning visits
- 20 gynecologic visits
- 20 perimenopausal/postmenopausal visits
Nurse midwifery students matriculate in a variety of academic programs and have various options including: diploma or associate degree (AD) registered nurse (RN) to certified nurse midwife (CNM) programs; BA/BS to RN/CNM-graduate programs; post-secondary programs; distance education; master's completion programs; and post-master's certificate programs.
Advanced education and training
The ACNM defines continuing education as an educational experience that goes beyond basic midwifery education. Nurse midwives may complete a variety of educational activities, including taking a national certification exam, attending workshops, and completing home study units of study.
The popularity and acceptance of nurse midwifery increased dramatically in the 1970s and 1980s. The number of nurse midwife attended births has steadily increased from year to year. Many more obstetricians and other healthcare providers have concluded that nurse midwifery is a safe, cost-effective way of managing normal pregnancies and deliveries. They are also coming to be accepted as primary care providers in managing women's health.
Intrapartum—Refers to labor and delivery.
Postpartum—Refers to the six-week period after childbirth. autonomy, allowing them to utilize the fullest extent of their training.
Varney, Helen. Varney's Midwifery, 3rd ed. Boston: Jones & Bartlett, 1997.
American College of Nurse Midwives (ACNM). 818 Connecticut Ave, Suite 900 Washington, DC 20006.(202) 728-9860. <www.acnm.org>.
ACNM. "About ACNM." 2000. <www.acnm.org/about/index.htm>.
ACNM. "Midwifery Education." 1999. <www.acnm.org/educ/index.htm>.
ACNM. "Professional Information." 2000. <www.acnm.org/prof/Index.htm>.
Nadine M. Jacobson, R.N.