The Online Journal Of Issues In Nursing.

Vol 19 2014 No 2 May 2014

Midwifery Practice and Education: Current Challenges and

Opportunities

Deborah Walker, DNSc, CNM, FACNM, FAAN

Barbara Lannen, MSN, CNM
Debra Rossie, MS, CNM

Abstract

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 climates influence on midwifery education, the contribution
of clinical sites and preceptors, and the benefits of midwifery education.

Citation: Walker, D., Lannen, B., Rossie, D., (May 31, 2014) "Midwifery Practice and
Education: Current Challenges and Opportunities" OJIN: The Online Journal of Issues in
Nursing Vol. 19, No. 2, Manuscript 4.

DOI: 10.3912/OJIN.Vol19No02Man04

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.

Regulatory barriers

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 midwifes 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 Medicines (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 states 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 organizations abilities and resources if they wish to be involved in
removing legislative barriers within their own states.

Business-related barriers

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 states defined scope of midwifery practice, even if it is within the
professions definition of midwifery basic or expanded scope of practice, then the
subsequent requirement to bill under a physicians 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 dont 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 persons 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 masters 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 masters degrees, 29
postgraduate certificates and 2 certificates) (ACNM, 2013c).

Many programs offer a traditional curriculum for BSN prepared RNs leading to a masters
or DNP degree. Four of the 39 midwifery programs offer a DNP only. Others offer an
accelerated program whereby non-RN students with a bachelors 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.

Students

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.

Conclusion

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 todays 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!

Authors

Deborah S. Walker, DNSc, CNM, FACNM, FAAN

Email: dswalker@wayne.edu

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 Nursings 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

Email: blannen@wayne.edu

Barbara Lannen completed her masters 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 & Womens Health Nurse Practitioner concentrations at WSU College of Nursing
since 2005, preparing new midwives and womens health nurse practitioners (WHNPs) to
face and overcome challenges.

Debra Rossie, MS, CNM

Email: debrossie@sbcglobal.net

Debra Rossie graduated from the University of Michigans 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 Detroits East Side. In addition to private practice, for the past
seven years she has held a faculty position in the Nurse-Midwifery and Womens 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.

References

Accreditation Commission for Midwifery Education (ACME). (2013). Criteria for

programmatic accreditation of midwifery education programs with instructions for
elaboration and documentation. Retrieved
from www.midwife.org/ACNM/files/ccLibraryFiles/Filename/000000003304/Prog%20Criteria
%2012%202009%20(rev%206%202013)%207%2025.pdf

American College of Nurse-Midwives (ACNM). (n.d.). State legislative and regulatory

guidance. Retrieved from http://www.midwife.org/index.asp?
bid=59&cat=11&button=Search

American College of Nurse-Midwives (ACNM). (2010). Midwifery education

programs.Retrieved from www.midwife.org/Education-Programs-Directory

American College of Nurse-Midwives (ACNM). (2011a). Standards for the practice of

midwifery. Retrieved
from www.midwife.org/ACNM/files/ACNMLibraryData/UPLOADFILENAME/000000000051/Sta
ndards_for_Practice_of_Midwifery_Sept_2011.pdf

American College of Nurse-Midwives (ACNM). (2011b). Position statement: Principles for

credentialing & privileging certified nurse-midwives & certified midwives. Retrieved
from http://www.midwife.org/ACNM/files/ACNMLibraryData/UPLOADFILENAME/0000000000
82/Principles%20for%20Credentialing%20&%20Privileging%20CNMs%20&%20CMs%20Mar
%2006.pdf KAREN- THIS NEEDS LINKED!

American College of Nurse-Midwives (ACNM). (2012a). Midwifery: Evidence-based practice.

A summary of research on midwifery practice in the United States. Retrieved
from www.midwife.org/ACNM/files/ccLibraryFiles/Filename/000000002128/Midwifery
%20Evidence-based%20Practice%20Issue%20Brief%20FINALMAY%202012.pdf

American College of Nurse-Midwives (ACNM). (2012b). Midwifery education trends report

2011. Retrieved
from www.midwife.org/ACNM/files/ccLibraryFiles/Filename/000000001457/MidwiferyEducati
onTrendsReport2011.pdf

American College of Nurse-Midwives (ACNM). (2012c). Definition of midwifery and scope of

practice of certified nurse-midwives and certified midwives. Retrieved
from www.midwife.org/ACNM/files/ACNMLibraryData/UPLOADFILENAME/000000000266/Def
inition%20of%20Midwifery%20and%20Scope%20of%20Practice%20of%20CNMs%20and
%20CMs%20Feb%202012.pdf.

American College of Nurse-Midwives (ACNM). (2012d). Mandatory degree requirements for

entry into midwifery practice. Retrieved
from www.midwife.org/ACNM/files/ACNMLibraryData/UPLOADFILENAME/000000000076/Ma
ndatory%20Degree%20Requirements%20Position%20Statement%20June%202012.pdf
American College of Nurse-Midwives (ACNM). (2012e). Core competencies for basic
midwifery practice. Retrieved
from www.midwife.org/ACNM/files/ACNMLibraryData/UPLOADFILENAME/000000000050/Cor
e%20Comptencies%20Dec%202012.pdf

American College of Nurse-Midwives (ACNM). (2013a). Fact sheet: CNM/CM-attended birth

statistics in the United States. Retrieved
from www.midwife.org/ACNM/files/ccLibraryFiles/Filename/000000003285/CNM-CM
%20Attended%20Birth%20Statistics%202013_FINAL.pdf

American College of Nurse-Midwives (ACNM). (2013b). Position statement: Collaborative

management in midwifery practice for medical, gynecologic and obstetric
conditions.Retrieved
from http://midwife.org/ACNM/files/ACNMLibraryData/UPLOADFILENAME/000000000058/C
ollaborative%20Mgmt%20May%202013.pdf

American College of Nurse-Midwives (ACNM). (2013c). Midwifery education trends report

2013. Retrieved
from www.midwife.org/ACNM/files/ccLibraryFiles/FILENAME/000000003743/ACNM_Midwifer
yEdTrend-2013-013114.pdf

American College of Nurse-Midwives (ACNM). (2014). Normal, healthy childbirth for women
& families: What you need to know. Retrieved
from http://ourmomentoftruth.midwife.org/ACNM/files/ccLibraryFiles/Filename/0000000031
84/NormalBirth_ConsumerDoc%20FINAL.pdf

American Midwifery Certification Board (AMCB). (2014a). 2013 annual report. Retrieved
from www.amcbmidwife.org/docs/annual-reports/2013-amcb-annual-report.pdf?sfvrsn=2

American Midwifery Certification Board. (2014b). Number of certificants 1971-present.

Retrieved from www.amcbmidwife.org/docs/default-document-library/certificants-1971---
present.pdf?sfvrsn=4

Block, J. (2007). Pushed: The painful truth about childbirth and modern maternity care.
Cambridge, MA: Da Capo Press.

Booth, J. W. (2007). An update on vicarious liability for certified nurse-midwives/certified

midwives. Journal of Midwifery & Womens Health, 52(2), 153-157.

Declercq, E. R., Sakala, C., Corry, M. P, Applebaum, S., & Herrlich, A. (2013). Listening to
mothers III: Pregnancy and birth. New York, NY: Childbirth Connection. Retrieved
from http://transform.childbirthconnection.org/wp-content/uploads/2013/06/LTM-
III_Pregnancy-and-Birth.pdf

Fagerlund, K., & Germano, E. (2009). The costs and benefits of nurse-midwifery education:
Model and application. Journal of Midwifery & Womens Health, 54(5), 341-350.

Fahy, K., Foureur, M., & Hastie, C. (2008). Birth territory and midwifery guardianship:
Theory, practice, education and research. Philadelphia, PA: Books for Midwives Press.
Institute of Medicine. (2010). The future of nursing: Leading change, advancing health.
Retrieved from www.iom.edu/~/media/Files/Report%20Files/2010/The-Future-of-
Nursing/Future%20of%20Nursing%202010%20Recommendations.pdf

King, T. L., Brucker, M. C., Kriebs, J. M., & Fahey, J. O., Gegor, C.L. & Varney, H.
(2013). Varneys midwifery Midwifery (5th ed). Burlington, MA: Jones and Bartlett Learning.

Lichtman, R., Varney Burst, H., Campau, N., Carrington, B., Diegmann, E. K., Hsia, L., &
Thompson, J. E. (2003). Pearls of wisdom for clinical teaching: Expert educators
reflect. Journal of Midwifery & Womens Health, 48(6), 455-463.

MacDorman, M. F., Declercq, E., & Mathews, T. J. (2013). Recent trends in out-of-hospital
births in the United States. Journal of Midwifery & Womens Health, 58(5), 494-501. doi:
10.111/jmwh.12092

Martin, J. A., Hamilton, B. E., Ventura, S. J., Osterman, M. J. K., & Mathews, T. J. (2013).
Births: Final data for 2011. National Vital Statistics Reports, 62(1). Hyattsville, MD: National
Center for Health Statistics. Retrieved
from www.cdc.gov/nchs/data/nvsr/nvsr62/nvsr62_01.pdf

National Council of State Boards of Nursing. (2008). Consensus model for APRN regulation:
Licensure, accreditation, certification & education. Retrieved
from www.ncsbn.org/Consensus_Model_for_APRN_Regulation_July_2008.pdf

Osterman, M.J.K., & Martin, J.A. (2014) Primary cesarean delivery rates, by state: Results
from the revised birth certificate 2006-2012. National Vital Statistics Reports, 63 (1).
Hyattsville, MD: National Center for Health Statistics.

Osterman, M.J.K. & Martin, J.A. (2013). Changes in cesarean delivery rates by gestational
age: United States, 1996-2011. NCHS Data Brief, 124. Hyattsville, MD: National Center for
Health Statistics.

Sandall, J., Soltani, H., Gates, S., Shennan, A., & Devane, D. (2013). Midwife-led continuity
models versus other models of care for childbearing women. Cochrane Database of
Systematic Reviews, Issue 8. Art. No.: CD004667. DOI:
10.1002/14651858.CD004667.pub3.

Wagner, M. (2001). Fish cant see water: The need to humanize birth. International Journal
of Gynaecology and Obstetrics, 75(Supple 1), S25-S37.

2014 OJIN: The Online Journal of Issues in Nursing

Article published May 31, 2014

Related Articles
Making the Case for Adult-Gerontology Critical Care Nurse Practitioner
Fellowships
Sherry Lynn Donaworth, DNP, ACNP, FNP (July 25, 2017)
 Full Practice Authority for Advanced Practice Registered Nurses is a
Gender Issue
Nancy Rudner Lugo, DrPH, APRN (May 4, 2016)

Challenges in Clinical Nurse Specialist Education and Practice

Jan Foster, PhD, APRN, CNS; Sonya Flanders, MSN, RN, ACNS-BC, CCRN (May 31,
2014)

Barriers to NP Practice that Impact Healthcare Redesign

Debra Hain, PhD, ARNP, ANP-BC, GNP-BC; Laureen M. Fleck, PhD, FNP-BC, CDE,
FAANP (May 31, 2014)

Addressing Issues Impacting Advanced Nursing Practice Worldwide

Ruth Kleinpell; Andrew Scanlon; Denise Hibbert; Freda DeKeyser Ganz; Linda
East; Debbie Fraser; Frances Kam Yuet Wong; Michelle Beauchesne (May 31,
2014)

Education and Practice Barriers for Certified Registered Nurse

Anesthetists
Debra P. Malina, CRNA, DNSc, MBA, ARNP; Janice J. Izlar, CRNA, DNAP (May 31,
2014)