NURSE-MIDWIFERY PRACTICE: Implications for the Future

In 1980, the American College of Nurse-Midwives celebrated its silver anniversary. Few of the original charter members of the ACNM could have possibly envisioned the spec- tacular growth that was to take place in nurse-midwifery during the next 25-year period. But, in fact the pro- fession grew from a small cadre of several hundred members to well over two thousand.

During this period of time, nurse- midwives undertook the most for- midable tasks and accomplished for the profession what many thought to be the impossible. As new educa- tional programs developed and existing programs expanded their en- rollments, the number of practition- ers grew. Public attention was drawn to nurse-midwifery as media reports spotlighted the return of the midwife. Health consumers in increasing numbers began to seek out the ser- vices of this newest member of the health team.

As obstetricians came to recognize the contributions that nurse-midwives were making to maternity care, joint practice arrangements between phy- sicians and nurse-midwives, gradually developed. The establishment of Birth- ing Centers marked the beginning of a new era in family-centered mater- nity care in the United States. Simul- taneously, nurse-midwives developed their own skills in interconceptual

care, supported the passage of legis- lation favorable to their cause, and negotiated with third party insurers for reimbursement for their services. The achievements over this 25-year period were truly remarkable.

The 21st century and the golden anniversary of the ACNM are ap- proaching. What challenges lie ahead? How will nurse-midwifery re- spond to them?

In a recent report, using mid-range projections, the Census Bureau is predicting that the total population of the United States will continue to grow until the middle of the next century. This means that the popula- tion will expand from the current es- timate of 232 million people to 268 million by the year 2000. What role will nurse-midwifery play in meeting their health care needs? Who will determine this?

Of particular importance to nurse- midwifery is the Census Bureau fore- cast that a significant change in the age distribution of the population will take place over the next 25 years. At the present time the median age of the population is 30.3 years. How- ever, a sharp rise in this figure is ex- pected to take place bringing the median age of the population to 36.3 by the year 2000. This will result in an increasingly larger seg- ment of the population in their golden years. As females enjoy a

Journal of Nurse-Midwifery ?? Vol. 28, No. 2, March/April 1983

Copyright @ 1983 by the American College of Nurse-Midwives

longer life expectancy than their male counterparts, the majority of this segment of the population will be women who are beyond the period of childbearing, family planning, or perhaps even childrearing. What are the implications for nurse-midwifey? Who will assume the responsibility for the health care of this growing number of healthy women?

Simultaneous with the forecast of an expanding population base is the Census Bureau projection that the number of annual births will begin to decline in 1988. What impact will this have on nurse-midwifery? Has the time come for nurse-midwives to in- corporate the health care of healthy women of all ages into their practice? This would expand nurse-midwifery’s sphere of clinical practice. It would not substitute for the services that the nurse-midwife now extends to the childbearing woman.

In 1990, a surplus of obstetricians and gynecologists is predicted. Many CNM’s believe that this does not augur well for nurse-midwifery. The assumption that a surplus of obstetri- cians and gynecologists will auto- matically distribute health manpower to all segments of the population is an erroneous one. Specialty trained physicians tend to establish their practices in large urban centers, par- ticularly those areas that are located adjacent to major medical com-

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plexes. As a consequence, large segments of the population who re- side in rural areas and in com- munities of less than 10,000 are un- derserved. The proposed surplus of obstetricians and gynecologists may, in@fact, exaggerate the maldistribu- tion of services that already exists. Consequently, the inequities in the distribution of health care services to the expanding population in small localities may persist. How will nurse-midwifery respond?

It is quite possible that the nurse- midwife’s practice in the large urban centers may be curtailed somewhat as the large concentration of obstetri- cal specialists will make competition for the obstetrical patient, particularly the intrapartal component, very keen. On the other hand, the feminist movement is well established and these articulate women will make their needs known. Their choices may not please the obstetrical spe- cialists.

Nurse-midwives are the only non-physician providers whose edu- cational preparation allows them to manage the uncomplicated labor and delivery. Nevertheless physician’s as- sistants and nurse practitioners carry out responsibilities that overlap those of nurse-midwives in some areas. The number of physician’s assistants involved in health care of women is very small and the expectation is that

it will remain so. However, the number of nurse practitioners who are trained to function in the area of women’s health care is expected to rise to 3900 in 1990 as compared to 4000-5000 C.N.Ms. What are the implications for nurse-midwifery? Midwifey has centuries of tradition and service to the childbearing woman. Maintaining this tradition is essential but does nurse-midwifery have to be bound by it to the exclu- sion of other services? Does nurse- midwifery want to confine itself to the childbearing period? In view of the proposed decline in the number of births, what are the prospects for continued government financial sup- port? Is there an urgency to incorpo- rate the care of healthy women within the framework of the nurse- midwife’s practice?

The number of nurse-midwives available for clinical practice will con- tinue to grow for some years to come. If enrollments in educational programs stabilize, the growth of nurse-midwifery as a profession will stabilize and then decline. There is a need to expand geographically into rural settings and develop the con- sumer support that has been such an asset to the growth of nurse-mid- wifery. What incentives are available to improve the accessibility of ser- vices in underserved areas? What mechanisms can be developed to

alert nurse-midwives to such incen- tives? Are there organized recruit- ment efforts that encourage potential candidates from rural areas to pursue nurse-midwifery? Have women’s groups been approached to support one student in a nurse-midwifery program? What contribution is nurse- midwifery making to quality care in rural areas at the present time?

The strong alliance that developed between nurse-midwives and health consumers during the first 25 years of the existence of the ACNM stemmed from the mutual interest each of them shared in family-oriented care during the childbearing period and a respect for the competence of the nurse-midwife as a clinical prac- titioner. By extending this practice to encompass the health care of healthy women throughout their life span, nurse-midwives can strengthen this alliance and bring a continuity of per- sonalized care to healthy women of all ages. The time to act is now.

The first 25 years of the College’s existence were marked by extraordi- nay accomplishments on the part of nurse-midwives. Will the tradition of achievement, already established, continue?

Patricia Rose, C.N.M., M.S. Associate Editor

Journal of Nurse-Midwifery ?? Vol. 28, No. 2, March/April 1983