The doctorate of nursing practice and entry into midwifery practice: Issues for consideration and debate.

The American College of Nurse-Midwives represents two cadres of midwifery professionals: certified nurse-midwives who are educated in both midwifery and nursing, and certified midwives who are educated in the discipline of midwifery. Certified nurse-midwives are designated by nursing professional organizations as advanced practice nurses. The United States nursing profession is advancing toward adoption of the Doctor of Nursing Practice degree, as the entry into practice credential for advanced practice nursing. There is no evidence to date to demonstrate differences in clinical practice outcomes between certified nurse-midwives and certified midwives. A secondary analysis of data from a series of compensation and benefits surveys did not demonstrate differences in salaries between respondents who held a practice-focused doctoral degree compared to a master's degree. The requirement of the practice-focused nursing doctoral degree for entry into midwifery practice for certified nurse-midwives would require additional evidence to support both a professional and a business case for such a change in policy. It would also require consideration of the professional and business impact that such a policy would have on certified midwives who do not hold the nursing credential. Equivalent entry into practice pathways would need to be developed.

The development of a consensus statement on normal physiologic birth: a modified Delphi study.

INTRODUCTION: This article describes the process of developing consensus on a definition of, and best practices for, normal physiologic birth in the United States. Evidence supports the use of physiologic birth practices, yet a working definition of this term has been elusive. METHODS: We began by convening a task force of 21 individuals from 3 midwifery organizations and various childbirth advocacy and consumer groups. A modified Delphi approach was utilized to achieve consensus around 2 research questions: 1) What is normal physiologic birth? and 2) What practices most effectively support its achievement? Answers to these questions were collected anonymously from task force members during multiple phases that included a preliminary briefing, an initial face-to-face roundtable, 9 iterative Delphi rounds, and reciprocal feedback from a wider audience of stakeholders at national and international conferences. Content analysis identified specific statements and concepts in the first Delphi round, which were subsequently ranked in following rounds. An initial draft was constructed based on the priorities that emerged and presented for feedback to peers and childbirth advocates whose comments were incorporated into the final document. RESULTS: Four key themes were identified from our initial questions; these provided the framework for the document: 1) definitions of normal physiologic birth, 2) mechanisms and outcomes of normal physiologic birth, 3) factors that influence normal physiologic birth, and 4) recommendations for increasing normal physiologic birth. These areas comprised the final sections in the multi-organizational consensus statement. DISCUSSION: The modified Delphi approach we employed allowed for the development of a consensus statement that will serve as a template for education, practice, and future research in maternity care. The completion of this statement marks the beginning of a project to promote systemic changes that support normal physiologic birth, and thus, have the potential to improve outcomes for mothers and infants.

The Midwifery Workforce: ACNM 2012 and AMCB 2013 Core Data.

INTRODUCTION: Core data are crucial for detailing an accurate profile of the midwifery workforce in the United States. The American College of Nurse-Midwives (ACNM) and the American Midwifery Certification Board, Inc. (AMCB), at the request and with support from the US Health Resources and Services Administration (HRSA), are engaged in a collaborative effort to develop a data collection strategy (the Midwifery MasterFile) that will reflect demographic and practice characteristics of certified nurse-midwives (CNMs) and certified midwives (CMs) in the United States. METHODS: Two independent datasets, one collected by ACNM in 2012 and one by AMCB in 2013, were examined to determine key workforce information. ACNM data were collected from the online Core Data Survey sent to ACNM members. AMCB data were extracted from information submitted online by applicants seeking initial certification in 2013 and applicants seeking to recertify following 5 years of initial certification. RESULTS: The ACNM 2012 survey was partially or fully completed by 36% (n = 2185) of ACNM members (N = 6072). AMCB respondents included 100% of new certificants (N = 539) and those applying for recertification in 2013 (n = 1323) of the total 11,682 certificants in the AMCB database. These two datasets demonstrate that midwives remain largely white, female, and older in age, with most engaged in clinical midwifery while employed primarily by hospitals and medical centers. Differences were reported between the ACNM membership and AMCB certification datasets in the numbers of midwives holding other certifications, working full-time, attending births, and providing newborn care. DISCUSSION: The new collaboration among HRSA, ACNM, and AMCB, represented as the Midwifery MasterFile, provides the opportunity to clearly profile CNMs/CMs, distinct from advanced practice registered nurses, in government reports about the health care workforce. This information is central to identifying and marketing the role and contribution of CNMs/CMs in the provision of primary and reproductive health care services.

Factors that influence midwives to serve as preceptors: an American College of Nurse-Midwives survey.

INTRODUCTION: Projected shortages in the primary care workforce underlie a need for more women's health care providers. In order to prepare more midwives to address this deficit, educators require additional clinical placement sites for students. The purpose of this study was to determine factors that influence practicing midwives to serve as preceptors. METHODS: An e-mail invitation to participate in an online survey was sent to 7658 current and lapsed members of the American College of Nurse- Midwives (ACNM), who provided ACNM with a valid e-mail address. The survey assessed factors that enabled or were barriers for midwifery preceptors. Forced-choice questions were analyzed using descriptive statistics. Participant comments were analyzed using qualitative descriptive methods. RESULTS: There were a total of 1517 surveys completed, for a response rate of 19.8%. Participants were primarily certified nurse-midwives (96.0%) who were in clinical practice (83.9%), with 78.0% in full-scope clinical practice. Participants represented all geographic regions of the United States. The majority of the participants indicated they or someone in their practice could precept a midwifery student. A commitment to the midwifery profession was the most commonly identified motivating factor (58.5%). Larger practices were more likely to precept midwifery students and to accept more than one student at a time. The most frequently identified barrier to precepting was the need to maintain a high patient volume (6.9%). Write-in comments were provided by approximately 500 participants and coded into 9 themes: payment, barriers to precepting, incentives, student characteristics, mechanisms for placement, communication, giving back, preceptor qualifications, and professional issues. DISCUSSION: There is a strong commitment from preceptors to give back to the profession through the teaching of the future generation of midwives. Many of the barriers to precepting could be addressed by ACNM, the Accreditation Commission for Midwifery Education, and individual midwifery education programs.

Findings from the analysis of the American College of Nurse-Midwives' membership surveys: 2009 to 2011.

INTRODUCTION: The American College of Nurse-Midwives (ACNM) Core Data Survey is an annual membership survey that collects demographic and selected workforce data about certified nurse-midwives (CNMs), certified midwives (CMs), and students enrolled in midwifery education programs accredited by the Accreditation Commission for Midwifery Education. These data are aggregated and published every 3 years. This article presents findings from the analysis of membership data for the years 2009 to 2011. METHODS: An online survey is sent annually to all ACNM members who provide ACNM with an e-mail address. The survey instrument for 2009 to 2011 focused on 5 categories: demographics, certification, education, employment, and licensure except for 2011, in which licensure data were collected separately. RESULTS: ACNM members responding to the surveys during 2009, 2010, and 2011 continued to remain predominantly white and female. The average age of CNMs/CMs in 2011 was 51.2 years. The majority had a master's degree as their highest degree, and 9.3% had a doctoral degree. Approximately two-thirds of respondents in each of the 3 survey years identified attendance at births as one of their primary responsibilities. DISCUSSION: Very little change in diversity was observed over the 3 survey years. The number of CNMs earning the doctor of nursing practice degree is increasing, whereas other doctoral degree categories remain stable. The majority of CNMs/CMs continue to identify a broad domain of clinical midwifery practice as their primary responsibility in their employment. The majority of respondents attend births, but the proportion has been decreasing slightly over time. Salaries for midwives continue to rise, but the reasons for this are unclear.

Midwives and liability: results from the 2009 nationwide survey of certified nurse-midwives and certified midwives in the United States.

INTRODUCTION: In partnership with the American College of Nurse-Midwives (ACNM), the authors conducted a survey of ACNM members to examine the incidence of lawsuit involvement, the outcomes of the litigation in which they were involved, and coping mechanisms among midwives who had been involved in a lawsuit. METHODS: In the spring of 2009, a nationwide Web-based survey was completed by ACNM members. In addition to using chi-square tests and nonparametric testing in data analysis, a logistic regression model was used to evaluate predictors of lawsuit involvement. RESULTS: Among 1340 midwives responding to the survey, 32% had been named in a lawsuit at least once. The median number of years in practice when the event leading to lawsuit occurred was 6. The majority of midwifery lawsuits involved hospital births and were settled prior to going to court. Three variables were statistically significant for involvement with litigation: the midwife's age, the number of births attended, and the ACNM region of practice in the United States. DISCUSSION: Lawsuits among midwives were significantly related to exposure to births over time. Practice patterns and job security were not greatly affected by the experience of a lawsuit. Future cyclic surveys are needed to track the frequency of litigation and the outcomes that lead to lawsuits and to better define the relationships between midwifery practice and medical malpractice litigation.

Osteoporosis update.

INTRODUCTION: Osteoporosis is a chronic disease that is estimated to affect more than 75 million people worldwide. The US Department of Health and Human Services projects that the disease will impact more than 10 million women by 2020 if efforts to prevent it are ineffective. This article provides an overview of the pathophysiology of osteoporosis, prevention measures, and an update of the US Food and Drug Administration-approved medications that are used in the treatment of this widespread disease. METHODS: The current literature on the pathology, risks, and treatment of osteoporosis was reviewed. Studies providing the evidence for best practices are included in the following sections: prevention, diagnosis, and treatment of osteoporosis. Current national standards for diagnosis and treatment are highlighted. RESULTS: Bisphosphonates continue to be the most popular and widely used pharmacologic treatment for osteoporosis. However, when bisphosphonates are contraindicated or cause side effects so serious that it is not possible for some women to use them, alternative pharmacologic treatments and forms of dosing are available. DISCUSSION: When lifestyle and dietary modifications are insufficient to offset a diagnosis of osteoporosis, there are a variety of pharmaceutical options available that will provide safe and effective protection against fracture due to osteoporosis.

Findings from the analysis of the American College of Nurse-Midwives' membership surveys: 2006-2008.

INTRODUCTION: The American College of Nurse-Midwives (ACNM) Core Data Survey is an annual membership survey that collects demographic and selected workforce data about certified nurse-midwives (CNMs), certified midwives (CMs), and students enrolled in midwifery education programs accredited by the Accreditation Commission for Midwifery Education, who are members of the organization. This article presents findings from the analysis of membership data for the years 2006 to 2008. METHODS: An e-mail invitation to participate in the online survey was sent to all ACNM members who provided ACNM with an e-mail address. A paper copy of the survey was available upon request. The survey instrument for the years 2006 to 2008 focused on five categories: demographics, certification, education, employment, and licensure. RESULTS: ACNM member respondents continue to remain predominantly white and female. The average age of CNMs/CMs for 2008 is 51 years, and the majority holds a master's degree as their highest degree. DISCUSSION: Very few advances have been made in the effort to increase the diversity of ACNM membership. The number of CNMs earning doctoral degrees (including the doctor of nursing practice degree) is increasing. A majority of CNMs/CMs continue to identify a broad domain of clinical midwifery practice as their primary responsibility in their primary employment, and hospitals and physician practices remain the largest employers of midwives. Salaries for midwifery-related work are rising, but it is unclear if midwives are earning more because salaries are higher or because the higher salaries reflect market wage adjustments that occur over time.

Demographic profiles of certified nurse-midwives, certified registered nurse anesthetists, and nurse practitioners: reflections on implications for uniform education and regulation.

TOPIC: There is wide variability in regulatory authority, basic education requirements, and titling for nurses in advanced practice roles, that is, certified nurse-midwives (CNMs), certified registered nurse anesthetists (CRNAs), and nurse practitioners (NPs). There is current advocacy for a common identity for advanced practice nurses (APNs), including uniform entry into practice requirements (the doctor of nursing practice [DNP]). METHODS: Membership survey data were extracted to generate a contemporary profile of characteristics of these categories of practitioners. RESULTS: The APN groups are similar in age (M = 47-48 years) and race (predominantly Caucasian), with the largest proportions of all groups clustering in the age range of 51-54 years. There are more men in the CRNA group (45%). CNMs have the highest proportion of doctoral degrees (4.7%). CRNAs command the highest annual average salary ($140,000). CONCLUSIONS: Membership survey data can monitor progress toward implementation of proposed educational and regulatory changes. The effect of these proposals on the availability of an experienced APN mentor workforce for DPN students and the availability of an APN workforce for clients remains largely unknown. Standardized indicators of performance and client outcomes may enhance current data collection of membership demographics and enable precise evaluation of outcomes and impact of APN care.

The National Practitioner Data Bank: information for and about midwifery.

The National Practitioner Data Bank (NPDB), mandated by federal legislation in 1986, serves as a mechanism to protect the public from unsafe practitioners who attempt to avoid discovery of prior negligent behavior or malpractice record(s) by moving from state to state. Reporting to the NPDB about malpractice payments on behalf of nurse-midwives began in 1990. Reporting of providers excluded from Medicare and Medicaid program participation began in September 1999. Practitioners who were already in an excluded status at that time were reported. Reports of adverse action against a nurse-midwife can be submitted to the NPDB by a state licensure board, a governmental agency, hospitals, health maintenance organizations, or other health care organizations. Reporting of licensing actions and clinical privilege actions are not required, although these may be voluntarily reported. The NPDB received 484 reports about nurse-midwives from September 1, 1999, to March 31, 2005. Of the 484 reports, 375 have an obstetric malpractice code. The median claim payment made on behalf of nurse-midwives during this period is 225,000 dollars. Although limited, the NPDB is the only systematic national source of nurse-midwifery malpractice data collection.

Presidential priorities: 50 years of wisdom as the basis of an action agenda for the next half-century.

Each of the living presidents of the American College of Nurse-Midwives (ACNM), past and current, was asked to select one or more issues that were of particular importance during her term(s) in office. Some of the issues identified by the presidents were amenable to review using existing quantitative data; this article presents those findings. The substantial increase in growth of ACNM membership in the 1980s and 1990s as well as the plateau that occurred at the beginning of the 21st century is documented. The relationship between ACNM and the professions of nursing, medicine, and other public health providers is illustrated. The increase in the number of Certified Nurse-Midwife/Certified Midwife (CNM/CM) education programs and the evolution and current profile of curriculum models are discussed. Finally, expansion of the scope of midwifery practice and the growing number of opportunities for entrepreneurial practice are presented in terms of current practice profiles, practice sites and settings, various employer-employee relationships, and the variety of financial reimbursement streams. This article is intended to complement the broader body of information about ACNM's history, and particularly, to supplement the richness of information derived from the qualitative and historical research inquiries conducted by others.

Findings from the analysis of the American College of Nurse-Midwives' membership surveys: 2000-2003.

Findings from the American College of Nurse-Midwives (ACNM) membership data provide descriptive information about selected characteristics of certified nurse-midwives (CNMs), certified midwives (CMs), and students enrolled in ACNM-accredited programs who are members of the organization. This article presents findings from the analysis of membership data for the years 2000 to 2003. Members remain predominantly white and female, with their age averaging in the mid-40s. Similarly, student demographics reflect little change from those reported in prior years. Students are primarily white, female, and in the mid-30s. Proportionately, there has been little increase in the diversity of members. The proportion of CNMs/CMs with a bachelor's degree continues to rise, as does the proportion of CNMs/CMs holding doctoral degrees. The majority of CNMs/CMs identified a broad domain of clinical midwifery practice as their primary responsibility in their primary employment, and hospitals remain the largest employer of responding midwives. The salaries of employed midwives appear to be increasing, although the modal salary (60,000 US dollars to 69,000 US dollars ) is unchanged from prior years. The profile of the membership has remained fairly constant, with small changes in the trend over time noted for age, employment patterns, and attendance at birth sites for the 4 years analyzed.