Heroism in Nursing Practice: Certified Nurse-Midwives

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We are heading into a maternity crisis where women do not have access to a qualified provider; this is coupled with some of the worst perinatal outcomes among developed countries.
Dr. Holly Powell Kennedy, Yale University

Certified nurse-midwives—advanced practice healthcare professionals with graduate-level degrees and credentialing—still struggle to practice autonomously in some U.S. states. The issue of practice authority varies widely by region, affecting the ability of CNMs to work in accordance with their high level of training and certification. Along with nurse practitioners, CNMs in some states such as California, Texas, and Florida operate under “restricted practice” conditions, which require these professionals to maintain cumbersome collaborative agreements with supervising physicians or otherwise limit their professional abilities. Considering the abundance of evidence that advanced practice nurses (including NPs and CNMs) offer safe, cost-effective healthcare with excellent patient outcomes and satisfaction, these restrictions present needless barriers in the profession.

The American College of Nurse Midwives (ACNM) has come out strongly in favor of full practice authority for CNMs. It states that, “safe, quality healthcare can best be provided when policy makers develop laws and regulations that permit CNMs and CMs to provide independent midwifery care within their scope of practice while fostering consultation, collaborative management, or seamless referral or transfer of care when indicated.” Dr. Holly Kennedy of Yale University, one of the CNM professors who graciously interviewed for this article, pointed out that this position is also supported by the American College of Obstetricians and Gynecologists (ACOG); the ACOG and ACNM released a joint statement promoting a collaborative care model among licensed, independent providers. Recognizing the expertise and strengths among autonomous members of a team is the best way to facilitate seamless, high-quality care for patients.

So who are the opponents of granting CNMs the ability to work in accordance with their level of credentialing and licensure? Not surprisingly, physicians’ groups such as the American Medical Association (AMA) consistently have been against granting full practice authority to APRNs. They argue that it’s about protecting patients, but the evidence is against them. Not only have countless studies demonstrated the professional effectiveness of NPs and CNWs, but from a free market perspective, expanding FPA will help address the looming shortage of healthcare providers; reduce unnecessary (and expensive) government regulations; and increase competition to create a high quality pool of providers. Countless organizations and think tanks (both liberal and conservative) have publicly supported granting FPA to APRNs, including:

  • Institute of Medicine
  • Bipartisan Policy Center
  • Cato Institute
  • National Governors Association
  • National Conference of State Legislatures
  • AARP
  • Federal Trade Commission
  • Department of Veterans Affairs

This story tackles the issue of full practice authority through the eyes of three exceptional CNM professors.

Interviews with the Experts: Three CNM Professors and Researchers

As of August 2017, NursePractitionerSchools.com had interviewed more than 30 APRNs on the issue of practice authority. The following interviews have been edited lightly for clarity and length.

Certified Nurse-Midwives and the Continued Fight for Full Practice Authority

There is no evidence to support restricting practice of CNMs. In fact the research shows the opposite. Independent midwifery care improves outcomes, reduces utilization of resources, and increases patient satisfaction.
Dr. Mayri Sagady Leslie, George Washington University

These three accomplished CNM professors and researchers are unanimous on the issue of full practice authority: presenting barriers to these healthcare professionals leads to patient confusion; compromises the ability of APRNs to start independent practices; can disrupt the continuity of care; and reduces the pool of autonomous healthcare providers, particularly in high-need regions. By illustration, the Journal of Midwifery & Women's Health (2016) reported that CNMs facilitate the births at one-third of rural maternity hospitals across nine states; not surprisingly, states with autonomous practice have a higher proportion of CNMs attending births, a boon for these high-need hospitals.

In sum, there are many compelling reasons for states to extend full practice authority to APRNs across the country. Drawing from interviews with more than 30 clinicians and professors as well as the wealth of research on the issue, extending FPA nationwide is expected to:

  • Facilitate access to healthcare providers, especially among vulnerable, high-risk populations and people in rural areas
  • Ameliorate the continuity of care
  • Assuage patient confusion over the role of APRNs
  • Iron out inefficiencies (e.g., confusing insurance disbursements)
  • Decrease the overall cost and increase consumer choice in healthcare

For working CNMs and others interested in FPA, there are several steps to get involved:

  • Participate in local, state, and national organizations, including the ACNM and the NCSBN
  • Give money to PACs who support pro-FPA political candidates
  • Contact representatives at all levels of government and provide evidence-based arguments for extending FPA
  • Make it clear to physician colleagues that APRNs are interested in collaboration and teamwork, not replacing doctors
  • Find mentors such as Dr. Kennedy, Dr. Cox, and Dr. Leslie who care about the issue and can provide guidance

Lastly, while the immediate threats to the Affordable Care Act have abated for now, there’s still a dedicated group of politicians seeking to undermine Title X and slash ACA’s maternity and newborn benefits, including proposed cuts to Planned Parenthood and Medicaid; notably, the Kaiser Family Foundation (2016) reported that Medicaid funds approximately half of births nationwide. This is a direct assault on women’s healthcare and empowering CNMs remains integral to the future of the country.

NursePractitionerSchools.com is an advertising-supported site. Featured programs and school search results are for schools that compensate us. This compensation does not influence our school rankings, resource guides, or other information published on this site.