Preparation of the Nurse-Midwife in the United States MARY CRAWFORD*

As president of the American College of Nurse-Midwifery, I consider it a great honor to have been asked to present a paper at this meeting. I deeply regret that I cannot be present to read this paper in person. In comparison to other countries of the world, midwifery in the United States is in a rather unusual position, having once been almost completely sup- planted by the male practitioner, now reborn in the light of broader perceptions and newly recognized needs. The World Health Organization defines maternity care as follows:

“The object of maternity care is to ensure that every expec- tant and nursing mother maintains good health, learns the art of child care, has a normal delivery, and bears healthy chil- dren. Maternity care in the narrower sense consists of the care of the pregnant woman, her safe delivery, her postnatal ex- amination, the care of her newly born infant, and the main- tenance of lactation. In the wider sense it begins much earlier in measures aimed to promote the health and well-being of the young people who are potential parents, and to help them to develop the right approach to family life and to the place of the family in the community.”

Our experience in the United States has led us to believe that, in our culture, good maternity care in the narrower sense can be provided for the greatest number in the hospital set- ting. In this setting the obstetrician, the midwife and the nurse can make their services avaiIabIe to the greatest number of mothers and babies. They can have at their finger tips the equipment and supplies needed in an emergency. Opportuni- ties €or research are expanded. We can learn more about pregnancy, labor and delivery, the puerperium, and the new-

*Mary Crawford, Associate Professor of Nursing, Columbia University. Presented at the Interarnerican Congress of Midwives, Chile, South America, in November, 1959.

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born in a shorter period of time. We can provide safer care for mothers and babies.

As we begin to achieve this safer maternity care, however, we have learned something else. Hospitalization has not been of much help in providing maternity care in the wider sense. There are times when it even may have been a hindrance. The mother has been transplanted out of her family setting for one of the most important experiences of her life. Other members of the family have had only the most limited experience, if any, with this whole process of childbearing and therefore cannot be of too much help. The mother as a person with individual needs for emotional support, and enough under- standing of the whole childbearing process to be able to help herself, often tends to become lost in this production line type of care. It might be said that we have taken two steps forward and one step backward. The next question is: Can we do better? We think we can, but not until we can learn to work as a team, each member contributing the best that he or she has to offer, and at the same time understanding and respect- ing the contribution of each of the other members of the team. Maternity care in this wider sense cannot be accomplished by the obstetrician alone or the midwife alone. It cannot even be accomplished by just the obstetrician and the midwife working together. We need the help of every member of the health pro- fession who may come in contact with parents and with poten- tial parents. If you believe this, it is not hard to see why the midwife has been reborn in the United States as the nurse- midwife. She will be the specialist in maternity nursing, but she will recognize and make use of the contribution which the nurse has to make as a member of our team. In order to achieve maternity care in this wider sense, we need the help of nurses, not only those working in maternity services, but those working in school health services, in public health, in industry, in pediatrics, medicine, and surgery, and in any other service in which she comes in contact with parents or potential parents. If the nurse-midwife is destined to play an important role in the planning and development of this kind of mater- N t y care, she needs a broad background of knowledge in this

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whole field of health. She needs a command of leadership skills. She must be able to participate in research and con- tribute to literature, as well as be thoroughly grounded in the art and science of obstetrics. She will be teaching, guiding, and to a greater or lesser extent, accomplishing her work through nurses. She must therefore understand, respect, and be able to work with nurses just as she understands, respects, and is able to work with the obstetrician.

This is what I believe we are striving for in the United States today. This is why the one universal requirement for entrance to our schools giving training in nurse-midwifery is that the applicant present evidence of graduation from an ap- proved school of nursing and, with the exception of foreign students, be licensed to practice in the United States. This is why we are striving to place our nurse-midwifery programs within a university setting. The report of the 1958 Work Con- ference on Nurse-Midwifery, published by the American College of Nurse-Midwifery, includes the following statement: “Education for nurse-midwives can best be provided in a uni- versity setting. This serves to establish the school on a secure and sable educational basis, to strengthen and enrich its edu- cational program, to attract a well qualified student body and faculty, to provide superior facilities for teaching and learning, and to secure recognition for the graduates in the form of a college or university degree.” This is also why several of our programs are set up on the graduate level in which applicants must present a baccalaureate degree which is acceptable to the university and students are candidates for the master’s degree. Even the certificate programs which do not offer an academic degree on completion of the program prefer their students to have the baccalaureate degree.

As you can see we are not aiming at the development of the independently practicing midwife in the United States, but rather at the development of midwifery as a nursing specialty. We are aiming at the development of an individual so thoroughly grounded in the art of midwifery and the science

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of obstetrics and with sufficient background in the social, be- havioral and public health sciences that she is able to partici- pate effectively not only in providing service to mothers and their families, but in the development and improvement of maternity care. She must be willing to accept her full responsi- bility for service to families. She must be able to respect her own contribution as well as that of other disciplines to the changing patterns of maternity care. Again to quote from the Report of the Working Committee on Nurse-Midwifery Educa- tion: “In looking to the future, schools of nurse-midwifery in the United States see themselves as preparing nurse-midwives to: (1) Participate with medical guidance, as members of a professional group, in the provision of maternity services in the hospitals, clinic, or home; (2) Train and supervise mid- wives and untrained birth attendants; (3) Teach nurses, fami- lies, and others the principles of good maternity care; (4) Administer, supervise, and consult in relation to maternity care in hospitals and in public health programs; (5 ) Participate in the systematic gathering and analysis of data for the purpose of evaluating services which affect the health of mothers and babies, and in implementing the findings.”

We have two kinds of nurse-midwifery programs in the United States today. The certificate programs which range from 6 to 12 months in length offer adequate training for the practice of nurse-midwifery. The graduate programs which lead to a master’s degree add to this by offering education in the functional areas of teaching, administration, or research. We are still experimenting with the best way to prepare the nurse-midwife to function and contribute to maternity care within our cultural setting. Education in nurse-midwifery in the United States is relatively new. Our oldest schools are less than thirty years old. For this reason there is considerable variation from one program to another. We encourage this because only through experimentation can we find new and better ways to help our students learn.

However, there is a common core which runs through all our programs. First of all, I think all our schools would agree that

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the content of the program should be dependent upon what the student will be doing after she finishes the program, not only immediately, but from a long range point of view. I think I can also say that one of the goals of all schools is to heIp the student develop a philosophy of maternity care which con- siders the mother and baby as part of a family, all of whom are affected by this experience and all of whom have mental, emotional, and spiritual, as we11 as physical needs to be met in relation to this experience.

Our feeling so far is that this kind of philosophy and an understanding of these needs can best be developed through continuity of care experiences. In other words, the student gets to know a certain number of mothers as early in pregnancy as possible and follows them throughout the maternity cycle. She learns about their families and even hopefully has an oppor- tunity to meet the other members of the family. She learns first-hand what their needs are.

Another thing that we're all aiming for, of course, is judg- ment and skill - the kind of judgment and skill which de- velop only through repeated experience in a variety of situa- tions, under guidance - yes, but also under circumstances in which the outcome of her own actions is her responsibility. Motivation for learning then reaches its highest level.

Finally, we want our students to come out of our programs skilled in the art of communication and teaching and with a mind that is continually searching for new and better answers. No matter what our students will be doing, these skills will be important if they are to do an effective job. Civilization does not stand still. What she learns today may not be very helpful ten years from now unless she continues to learn. She needs the kind of scientific background which will give her confidence in her own ideas and enable her to think for her- self, maintaining the questioning mind that will enable her to discover new facts and develop new ways. She needs to be able to sell her ideas to others both on a professional level and on a lay level. She must have enough understanding of human

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behavior and cultural influence to be able to adjust her idem and teaching to the ideas of others and to the changing pat- terns of civilization. Rather than jealously guarding the bow- ledge and skiIIs which she has gained, she must be able to recognize when these knowledges and skills can be passed safely on to others and be willing to do so as she continually gains new knowledge and skill herself. If we are to accomplish maternity care in its widest sense, we as nurse-midwives must be prepared not only to increase our own knowledge and understanding, but to make our contribution to the know- ledge and understanding of the obstetrician, our fellow mid- wives, nurses, and other members of the health teams including the parents themselves and all of those who some day will be parents.

As you can see, we have set our goals high. We have a long way to go in attaining these goals. We are convinced, however, that these goals can be attained - that we, as nurse-midwives, have an essential contribution to make in the accomplishment of the best kind of maternity care.

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