Chapter 6. Certified Nurse Midwives

• Introduction
• The Original Practice Environment Index for CNMs
• The New Professional Practice Index for CNMs
• Conclusions
• Detailed scoring sheets for CNMs for each of the 50 States can be found in Appendices C and F.

The profession of midwifery has a history spanning both centuries and geography and is arguably the most publicly known of the professions that are subjects of this research. CNMs are healthcare providers who combine the skills of nursing with the competencies of midwifery. Midwives have a special focus on childbirth guided by an orientation that birth is a normal physiological process not an illness.

Presently, nurse midwives provide birthing services but their practice is also augmented by skills obtained in advanced education to include well women health care and educational services as well as family planning services. Nurse midwives attend just under 10 percent of all vaginal births in the United States.^[33] Contrary to public perception, 99 percent of these births occur in a hospital or birthing center with less than 1 percent occurring in homes.^[34]

Nurse Midwives are currently licensed in every State. Some States regulate nurse midwifery as a separate profession while others regulate the profession as a special class of nurse in advance practice nurse legislation.  In most States, the Board of Nursing governs the profession. Nurse Midwives are separately regulated by a Board of Midwifery in only two States, Utah and New York. The legal status and scope of practice of midwives varies significantly across the 50 States and the District of Columbia.

The original CNM practice environment index developed by Sekscenski et al for 1992 was based on three broad criteria and point allocations reflecting the then present practice environment for the profession. The specific criteria and point allocations used in creating the index were Legal Status (Maximum Score  = 20);  Reimbursement (Maximum Score = 40); and Prescriptive Authority (Maximum Score = 40). The detailed point allocations for the original index for CNMs are presented in Table C-3 in Appendix C.

The original professional practice index scores for CNMs for the 50 States resulting from the criteria in Table C-3 in Appendix C are summarized in Table 6-1. The scores show a definite trend toward greater professional practice options across the fifty States and the District of Columbia between 1992 and 2000. The increases in the index scores indicate greater professionalization, socialization, and standardization of professional practice for CNMs over the last decade.

To better reflect the subtle differences that often exist in professional practice across the 50 States, a new index was developed as part of this study that incorporates more criteria and more variability in the scores assigned. The new professional practice index more accurately reflects the practice environments of CNMs across the U.S. in 2000.

Table 6-1 shows that most States scored lower on the new 2000 index than on the original 2000 index. This is an indication of the impact of the changing health care delivery system which places greater demands and requirements on health professionals in both clinical practice and practice management. For example, statutes defining Managed Care Organizations added new reimbursement options for CNMs between 1992 and 2000 in many States.

The scores on the original CNM practice environment index reveal a trend toward more practice options for CNMs across the fifty States and the District of Columbia between 1992 and 2000. The scores indicate the trend towards greater professionalization, socialization, and standardization of the CNM profession over the last decade. Additional analyses of the index scores are described and summarized in Chapter 7.

As is true with many such indices, the true differences that underlie small differences in the scores are generally very small. Thus, States that are close on any the indices are not significantly different in their professional practice. The authors have applied a qualitative overlay to the new index scores to identify States they believe provide Excellent, Favorable, Acceptable, Limiting, and Restrictive environments for CNMs. These are not hard-and-fast terms or categories, and they are provided only to help readers to characterize the practice environments in the different states in a more qualitative way. The terms do generally conform to characterizations of the practice environments in States by knowledgeable CNMs.

Comparisons of individual CNM professional practice scores on a State-by-State basis should be made with caution. The scores reflect general, not particular, conditions in the State regulatory environments. Comparing one State with another on the Sekscenski index may not fully indicate the similarities or differences in actual practice patterns. The index is a good indicator of the trend toward broader practice environments, but it does not effectively capture the detailed variations in State requirements.