Serving women in need: nurse-midwifery practice in the United States

Nurse-midwifery practices in the United States were examined to study the relationship between certified nurse-midwives' (CNMs) demographic, work setting, and practice characteristics in terms of clientele, practice size, and practice type. Factors that might influence the ability of CNMs to serve populations at risk for poor outcomes were given particular attention.

A total of 2,405 responses to a 1998 mailed survey of 6,365 nurse-midwives ever-certified by the American College of Nurse-Midwives were analyzed.

Study results indicated that CNMs continue to serve a population who are, based on a social risk profile, disproportionately at risk for poor pregnancy outcomes, including women who are uninsured (16%), immigrant (27%), adolescent (29%), and women of color (50%). It was also found that clientele varied according to practice settings: CNMs working in non-hospital, nonprofit settings served a clientele that was 65% nonwhite, 44% immigrant, 40% adolescent, and 29% uninsured; these CNMs received 61% of their client payments from Medicaid. CNMs working in private offices or for managed care organizations were less likely to serve women with these characteristics.

Study results, taken in conjunction with research that documents the safety of nurse-midwifery practice, reinforce policy recommendations that support expanded access to nurse-midwifery services. Findings also indicate a need for further research in the areas of CNM workload and productivity in managed care settings and the association between CNM race and ethnicity and the race and ethnicity of their clients.