Minimal Intervention — Nurse-Midwives in the United States
http://www.100md.com
《新英格兰医药杂志》
I first observed childbirth in 1973 during a rotation at the Boston Lying-In Hospital, where I witnessed many women in labor screaming in a scopolamine stupor. What I remember most vividly were not the physicians and nurses, competent though they may have been, but the British-trained nurse-midwives who practiced as labor nurses. Their competence, confidence, and compassion had a calming effect on everyone in the room (including this terrified student-nurse). The experience was so gripping, in fact, that I left the hallowed halls of New England Deaconess Hospital for the hollows of Kentucky to enter the Frontier Nursing Service School of Nurse-Midwifery and become a certified nurse-midwife.
My earliest assumptions about the birthing process were somewhat naive; I soon learned that birth was not always as normal or uncomplicated as I had believed. A review of my student-midwifery log from 1977 detailing the first 100 births I attended bears out this lesson. The first six women mentioned had complications and conditions that included rape, severe preeclampsia, diabetes, gonorrhea, a complete abruptio placenta, disseminated intravascular coagulation, mental retardation, and arrested labor. All but one of these deliveries required close collaboration with physicians. Thanks to the attending physicians, midwifery "tutors," and my training in managing "normal" births, all went well. Those early years indelibly impressed on me the importance of collegiality and collaboration.
Historically, the first nurse-midwives in this country were members of a pioneer profession that served the poor.1 The most important period of development in nurse-midwifery began in the 1920s, when, in order to address high maternal and infant mortality, they provided maternity care in areas that lacked it. Turning to the British model of maternity care, the Frontier Nursing Service initiated the first nurse-midwifery program in the United States. Through the leadership of Mary Breckenridge, British-trained midwives were recruited to rural Kentucky to "safeguard the lives and health of mothers and children." Their care resulted in marked reductions in maternal and infant mortality. In 1932, the Maternity Center Association opened, in Harlem, the first educational program for nurse-midwives in the United States. By 1944, six schools were educating nurse-midwives, including the Catholic Maternity Institute in New Mexico, which aimed to provide maternity care for the poor, Spanish-speaking population of the Santa Fe area.
(Figure)
Certified Nurse-Midwife Instructor and Two Student Nurse-Midwives Attending a Home Birth in East Harlem, 1950s.
Courtesy of Ruth Beeman.
Training for nurse-midwifery is rigorous. Nurse-midwives are educated in both nursing and midwifery and graduate from a program accredited by the American College of Nurse-Midwives (ACNM). In order to practice, they must pass an examination for certification by a national board. Today, 42 graduate educational programs, a number of them at prestigious medical institutions, offer master's degrees in public health, master's degrees in science and nursing, and doctoral degrees. Education focuses on the management of women's health care, particularly pregnancy, childbirth, the postpartum period, care of the newborn, and gynecology. The training promotes a noninterventional, individualized approach to normal pregnancy and childbirth, involving a certain amount of education of women — an approach that is often time-consuming. Given the rise of managed care and complex new payment systems, it is increasingly difficult to pursue such an approach.
Founded nearly 50 years ago, the ACNM accredits midwifery-education programs, administers continuing-education programs, establishes clinical-practice standards, builds liaisons with state and federal agencies,2 and works with the American College of Obstetricians and Gynecologists to facilitate communication between obstetrician-gynecologists and nurse-midwives. Its standards for midwifery practice require integration into a health care system that involves consultation, collaborative management, and referral. Today, approximately 6200 nurse-midwives are in clinical practice nationwide — a relatively small number as compared with the 45,000 board-certified obstetrician-gynecologists, 17,000 family-practice physicians, and other physicians who attend the nearly 4 million births that occur each year. Despite their relatively small numbers, however, nurse-midwives attended 10 percent of live births involving vaginal delivery in the United States in 2001, a marked increase from less than 5 percent in 1989 (see Figure).
Figure. Live Births Attended by Certified Nurse-Midwives, 1989–2001.
Data are from Declercq.3
According to a national survey in the early 1990s, most women cared for by nurse-midwives were considered to be at risk for adverse health outcomes because of cofactors such as poverty, refugee status, and ethnic background.2 The women served by nurse-midwives are known to have relatively low rates of obstetrical interventions and procedures, such as induction of labor, episiotomy, the use of epidural anesthesia, and cesarean delivery.2 They also report high levels of satisfaction, and the models of care used by nurse-midwives have been shown to be cost effective.2 Nearly half of nurse-midwives are employed by physician practices and hospitals; in nearly all states, nurse-midwives have prescription-writing authority. Medicaid reimbursement for the services they provide is mandatory in all states, 33 of which also require reimbursement by private insurance companies.
(Figure)
Certified Nurse-Midwife Attending a Laboring Woman in a Birth Center in Washington State, 1990s.
Courtesy of Janice Sachs-Ory.
Collaboration between physicians and midwives remains important. The challenge is to interpret the estimated benefit of the approach traditionally used by midwives, with its intensive bedside presence and minimal intervention, as a contribution to the collaborative enterprise of obstetrics and gynecology. Will society continue to value and support this contribution? We have entered the new millennium in the midst of a childbirth crisis. Our recent national statistics show ever-increasing use of intrapartum interventions such as induction of labor (in 21 percent of deliveries) and cesarean delivery (26 percent), as well as poor perinatal outcomes such as preterm delivery (12 percent) and low birth weight (8 percent).4 If maternity care in the United States is to improve, I believe that the reversal of these trends will require the input and collaboration of professionals in midwifery, medicine, public health, and public policy.
Nurse-midwives alone cannot solve all the problems in our maternity care system, but a broader understanding of their role might have important benefits. In most European countries where midwifery practice still dominates maternity care, the involvement of midwives is associated with good perinatal health outcomes. For example, midwives in Ireland, Scotland, and England deliver more than 65 percent of all babies, and the proportions in Denmark, Sweden, Norway, Finland, and Germany exceed 85 percent. These countries have fewer obstetrical interventions than the United States, as well as lower maternal, neonatal, and infant mortality rates and higher rates of breast-feeding. Of course, their health care delivery systems also differ from ours in other significant ways — for instance, there are fewer economic and practical barriers to obtaining maternity care and extended, paid maternity leave — making the potential translation of results far from simple.
In 1925, obstetrician and nurse leaders were convened to assess the need for midwifery-training programs in the United States, and the result, one participant reported, "was a bitter meeting, for a number of the leaders of obstetrics and nursing believed that there was no place for the nurse-midwife, and the time had come when we must eliminate midwifery entirely from our social scheme."1 Nearly 80 years later, turf battles have not gone away, yet they have diminished. It is time, I believe, to dismiss divisive rhetoric and to commit ourselves collectively and collaboratively to approaches that provide women with the safest and most effective care for pregnancy and childbirth.
Source Information
From the Schools of Nursing and Public Health and Community Medicine, University of Washington, Seattle.
References
Shoemaker MT. History of nurse-midwifery in the United States. New York: Garland Publishing, 1984.
American College of Nurse-Midwives home page. (Accessed October 14, 2004, at http://www.acnm.org/.)
Declercq E. Percentage of live births attended by CNMs in the United States, 1989-2001. J Midwifery Womens Health 2004;49:78-79.
Martin JA, Hamilton BE, Sutton PD, Ventura SJ, Menacker F, Munson ML. Births: final data for 2002. Natl Vital Stat Rep 2003;52:1-113.(Mona T. Lydon-Rochelle, C)
My earliest assumptions about the birthing process were somewhat naive; I soon learned that birth was not always as normal or uncomplicated as I had believed. A review of my student-midwifery log from 1977 detailing the first 100 births I attended bears out this lesson. The first six women mentioned had complications and conditions that included rape, severe preeclampsia, diabetes, gonorrhea, a complete abruptio placenta, disseminated intravascular coagulation, mental retardation, and arrested labor. All but one of these deliveries required close collaboration with physicians. Thanks to the attending physicians, midwifery "tutors," and my training in managing "normal" births, all went well. Those early years indelibly impressed on me the importance of collegiality and collaboration.
Historically, the first nurse-midwives in this country were members of a pioneer profession that served the poor.1 The most important period of development in nurse-midwifery began in the 1920s, when, in order to address high maternal and infant mortality, they provided maternity care in areas that lacked it. Turning to the British model of maternity care, the Frontier Nursing Service initiated the first nurse-midwifery program in the United States. Through the leadership of Mary Breckenridge, British-trained midwives were recruited to rural Kentucky to "safeguard the lives and health of mothers and children." Their care resulted in marked reductions in maternal and infant mortality. In 1932, the Maternity Center Association opened, in Harlem, the first educational program for nurse-midwives in the United States. By 1944, six schools were educating nurse-midwives, including the Catholic Maternity Institute in New Mexico, which aimed to provide maternity care for the poor, Spanish-speaking population of the Santa Fe area.
(Figure)
Certified Nurse-Midwife Instructor and Two Student Nurse-Midwives Attending a Home Birth in East Harlem, 1950s.
Courtesy of Ruth Beeman.
Training for nurse-midwifery is rigorous. Nurse-midwives are educated in both nursing and midwifery and graduate from a program accredited by the American College of Nurse-Midwives (ACNM). In order to practice, they must pass an examination for certification by a national board. Today, 42 graduate educational programs, a number of them at prestigious medical institutions, offer master's degrees in public health, master's degrees in science and nursing, and doctoral degrees. Education focuses on the management of women's health care, particularly pregnancy, childbirth, the postpartum period, care of the newborn, and gynecology. The training promotes a noninterventional, individualized approach to normal pregnancy and childbirth, involving a certain amount of education of women — an approach that is often time-consuming. Given the rise of managed care and complex new payment systems, it is increasingly difficult to pursue such an approach.
Founded nearly 50 years ago, the ACNM accredits midwifery-education programs, administers continuing-education programs, establishes clinical-practice standards, builds liaisons with state and federal agencies,2 and works with the American College of Obstetricians and Gynecologists to facilitate communication between obstetrician-gynecologists and nurse-midwives. Its standards for midwifery practice require integration into a health care system that involves consultation, collaborative management, and referral. Today, approximately 6200 nurse-midwives are in clinical practice nationwide — a relatively small number as compared with the 45,000 board-certified obstetrician-gynecologists, 17,000 family-practice physicians, and other physicians who attend the nearly 4 million births that occur each year. Despite their relatively small numbers, however, nurse-midwives attended 10 percent of live births involving vaginal delivery in the United States in 2001, a marked increase from less than 5 percent in 1989 (see Figure).
Figure. Live Births Attended by Certified Nurse-Midwives, 1989–2001.
Data are from Declercq.3
According to a national survey in the early 1990s, most women cared for by nurse-midwives were considered to be at risk for adverse health outcomes because of cofactors such as poverty, refugee status, and ethnic background.2 The women served by nurse-midwives are known to have relatively low rates of obstetrical interventions and procedures, such as induction of labor, episiotomy, the use of epidural anesthesia, and cesarean delivery.2 They also report high levels of satisfaction, and the models of care used by nurse-midwives have been shown to be cost effective.2 Nearly half of nurse-midwives are employed by physician practices and hospitals; in nearly all states, nurse-midwives have prescription-writing authority. Medicaid reimbursement for the services they provide is mandatory in all states, 33 of which also require reimbursement by private insurance companies.
(Figure)
Certified Nurse-Midwife Attending a Laboring Woman in a Birth Center in Washington State, 1990s.
Courtesy of Janice Sachs-Ory.
Collaboration between physicians and midwives remains important. The challenge is to interpret the estimated benefit of the approach traditionally used by midwives, with its intensive bedside presence and minimal intervention, as a contribution to the collaborative enterprise of obstetrics and gynecology. Will society continue to value and support this contribution? We have entered the new millennium in the midst of a childbirth crisis. Our recent national statistics show ever-increasing use of intrapartum interventions such as induction of labor (in 21 percent of deliveries) and cesarean delivery (26 percent), as well as poor perinatal outcomes such as preterm delivery (12 percent) and low birth weight (8 percent).4 If maternity care in the United States is to improve, I believe that the reversal of these trends will require the input and collaboration of professionals in midwifery, medicine, public health, and public policy.
Nurse-midwives alone cannot solve all the problems in our maternity care system, but a broader understanding of their role might have important benefits. In most European countries where midwifery practice still dominates maternity care, the involvement of midwives is associated with good perinatal health outcomes. For example, midwives in Ireland, Scotland, and England deliver more than 65 percent of all babies, and the proportions in Denmark, Sweden, Norway, Finland, and Germany exceed 85 percent. These countries have fewer obstetrical interventions than the United States, as well as lower maternal, neonatal, and infant mortality rates and higher rates of breast-feeding. Of course, their health care delivery systems also differ from ours in other significant ways — for instance, there are fewer economic and practical barriers to obtaining maternity care and extended, paid maternity leave — making the potential translation of results far from simple.
In 1925, obstetrician and nurse leaders were convened to assess the need for midwifery-training programs in the United States, and the result, one participant reported, "was a bitter meeting, for a number of the leaders of obstetrics and nursing believed that there was no place for the nurse-midwife, and the time had come when we must eliminate midwifery entirely from our social scheme."1 Nearly 80 years later, turf battles have not gone away, yet they have diminished. It is time, I believe, to dismiss divisive rhetoric and to commit ourselves collectively and collaboratively to approaches that provide women with the safest and most effective care for pregnancy and childbirth.
Source Information
From the Schools of Nursing and Public Health and Community Medicine, University of Washington, Seattle.
References
Shoemaker MT. History of nurse-midwifery in the United States. New York: Garland Publishing, 1984.
American College of Nurse-Midwives home page. (Accessed October 14, 2004, at http://www.acnm.org/.)
Declercq E. Percentage of live births attended by CNMs in the United States, 1989-2001. J Midwifery Womens Health 2004;49:78-79.
Martin JA, Hamilton BE, Sutton PD, Ventura SJ, Menacker F, Munson ML. Births: final data for 2002. Natl Vital Stat Rep 2003;52:1-113.(Mona T. Lydon-Rochelle, C)