Midwifery and the Crowning of Health Care Reform

Abstract

BACKGROUND In July 2009, the American College of Nurse-Midwives (ACNM) sent a letter to members of Congress opposing the federal recognition of certified professional midwives (CPMs) under the Social Security Act. 1 The Social Security Act is the piece of legislation that provides for national health care coverage, such as Medicare and Medicaid, for elders, the socioeconomically disadvantaged, military personnel, and persons with disabilities. Although the Social Security Act was signed by President Roosevelt in 1935, certified nurse-midwives (CNMs) were not included in coverage by this act until 1988. Only in the past 10 years was the act expanded to include coverage for the full scope of care provided by CNMs and certified midwives (CMs). CNMs/CMs have struggled valiantly to create a recognized, fairly reimbursed, autonomous profession in the face of political and economic opposition from nurses and physicians. Part of their success in forging the CNM/ CM profession is attributable to the academic model they developed to train midwives. 2 In the letter to members of Congress, ACNM contended that midwifery services provided by CPMs should not be covered under the Social Security Act because graduation from an accredited program is not a requirement for national CPM certification by the North American Registry of Midwives (NARM). To be eligible to sit for the NARM written examination, individuals may complete their education through an apprenticeship, a Midwifery Education Accreditation Council (MEAC)-accredited education program, or an ACNM Accreditation Commission for Midwifery Education (ACME)-accredited education program. 3 If a midwife passes the NARM examination, no distinction is made in her CPM credential based upon her route of education. The concern ACNM expressed to Congress members is only with midwives who are not trained through an accredited program. However, it is difficult to substantiate ACNM's concern because CPMs are not differentiated based upon educational route. While graduation from an accredited education program is the standard preparation for health care providers in the United States and other countries, the question remains: Is midwifery preparation through an accredited education program inherently better than midwifery preparation through an unaccredited apprenticeship process? Unfortunately, no data are available to answer this question.

A critical interpretive synthesis of the roles of midwives in health systems

“…consumer and religious groups), researchers, professional and international associations, and donor agencies • Policies are influenced by interests that have concentrated benefits and diffuse costs • Interest groups play a role in supporting or opposing the integration of midwifery in the health system • In LMICs, bilateral and multilateral donors work alongside local governments • In HICs, professional associations play a strong role in political lobbying • Interests are closely related to institutions (policy networks) as well as ideas as interest groups often reflect and/or can influence societal values • Interest groups play an important role in advancing midwifery in the health system by (1) creating partnerships to improve SRHR [ 45 , 67 ]; (2) promoting regulation and accreditation (e.g. accreditation requirements, setting standards, policies and guidelines) [ 63 , 68 – 70 ]; (3) capacity-building, including midwifery research [ 71 , 72 ]; (4) policy leadership and decision-making [ 43 ]; and (5) lobbying governments/advocacy [ 73 , 74 ] • Strong physician and hospital interest groups created a monopoly over maternity care (United States, Canada, Australia, and Mexico) [ 37 , 38 , 51 , 55 , 75 – 77 ] and impede midwives from practicing to their full scope [ 78 , 79 ] • Tensions within the profession between nurse midwives and midwives (United States) [ 80 ] • Marginalisation of midwifery through dominant stakeholder groups [ 50 ] • Competing interests from nursing organisations created interprofessional tensions (Nepal) and limited establishing midwifery as an independent profession [ 81 ] • Barriers existed in accessing evidence published by African midwives (e.g. African nursing and midwifery research is often published in non-indexed journals) [ 72 ] • Creation of interest groups to participate in the policy-making process [ 4 ] and strengthening existing groups in order to participate in the decision-making process (Nepal) [ 81 , 82 ] • Consultations with interest groups to create culturally safe midwifery care (Canada) [ 34 , 56 – ...…”

“…accreditation requirements, setting standards, policies and guidelines) [ 63 , 68 – 70 ]; (3) capacity-building, including midwifery research [ 71 , 72 ]; (4) policy leadership and decision-making [ 43 ]; and (5) lobbying governments/advocacy [ 73 , 74 ] • Strong physician and hospital interest groups created a monopoly over maternity care (United States, Canada, Australia, and Mexico) [ 37 , 38 , 51 , 55 , 75 – 77 ] and impede midwives from practicing to their full scope [ 78 , 79 ] • Tensions within the profession between nurse midwives and midwives (United States) [ 80 ] • Marginalisation of midwifery through dominant stakeholder groups [ 50 ] • Competing interests from nursing organisations created interprofessional tensions (Nepal) and limited establishing midwifery as an independent profession [ 81 ] • Barriers existed in accessing evidence published by African midwives (e.g. African nursing and midwifery research is often published in non-indexed journals) [ 72 ] • Creation of interest groups to participate in the policy-making process [ 4 ] and strengthening existing groups in order to participate in the decision-making process (Nepal) [ 81 , 82 ] • Consultations with interest groups to create culturally safe midwifery care (Canada) [ 34 , 56 – 58 ] • Professional interest groups came together to strengthen health systems through (1) awareness campaigns; (2) lobbying (agenda-setting); and (3) training, advocacy and coalitions of interested stakeholders to inform education and policy [ 11 , 66 – 68 , 83 ] • Midwifery organisations used counter social movements to influence public opinion [ 49 ] • Researchers advocated for evidence-informed policies on midwifery [ 47 ] • Collaborative networks of health professional groups raised awareness of rising caesarean rates (Latin America) [ …”

“…conflict, epidemics, and natural disasters) [ 46 ] • Effective collaboration between governmental institutions and professional associations supported quality midwifery education [ 107 ] • Integrated data collection and analysis into regional and national health information systems supported monitoring and evaluation processes for evidence-informed decisions [ 63 ] [ 1 – 4 , 6 , 8 , 10 – 13 , 34 , 35 , 38 , 39 , 43 , 45 – 48 , 50 , 52 , 53 , 55 , 56 , 58 , 59 , 62 , 63 , 65 , 68 – 71 , 74 , 77 , 78 , 80 , 82 , 84 , 86 , 87 , 90 , 91 , 93 – 100 , 105 – 109 , 111 – 116 ] Financial arrangements Financing systems • Financing systems: (1) Medicare has been funded by a mix of federal government cash payment to provinces, province- specific taxes and federal government (Canada) [ 6 ]; (2) mixed health system — public and private financing, health insurance, and service delivery and the public system is supported by the National Health Fund, which covers almost 75% of the population (Chile) [ 84 ]; and (3) effective coverage — the proportion of the population who ne...…”

“…• Lack of legislation to support regulatory activities [ 34 , 43 , 48 , 58 , 71 , 82 , 87 , 93 , 94 ] limited recognition and scope [ 38 , 87 ] and the ability to practice as an autonomous profession [ 80 ]…”

Home Birth in North America: Attitudes and Practice of US Certified Nurse‐Midwives and Canadian Registered Midwives

“…In CNM/CM programs, hospital‐based intrapartum clinical practicums are a core component of curricula, birth center practicum exposure is occasional, and home birth practicums are rare and not required. In contrast, attendance at home birth is a standard requirement for CPM credentialing, but opportunities for hospital practice education are rare and not required . Continuity of care and an evidence‐based, low‐intervention philosophy are common values for all types of US midwives, but they are not embedded in regulatory practice requirements.…”