• Mary-Scovill Elder C.N.M., M.S.

Traditionally, advertising by professionals has been regulated by extremely restrictive codes of professional ethics. However, due to several Supreme Court decisions, most notably Bates v. State Bar of Arizona[1] which upheld the constitutionality of the rights of attorneys to advertise their fees for routine legal services in newspapers, increasing numbers of professionals are beginning to advertise. Proponents of advertising are not only instigating numerous legal actions designed to eliminate restrictions against advertising by professionals but also are lobbying for changes in state laws and regulations which prohibit or severely restrict professional's advertising and soliciting activities. The recent change in the American Medical Association's (AMA) Code of Medical Ethics permitting physicians to advertise their fees and services was prompted by a Federal Trade Commission (FTC) charge that the AMA had used its ban on soliciting business by advertising to prevent or hinder competition among physicians. The learned professions, including nurse-midwifery, are no longer immune from antitrust laws.

To advertise or not to advertise is no longer the question. Rather the questions are, what to advertise and how to advertise. Will advertising have an adverse affect on professionalism? Is advertising of professional services inherently misleading? What are the economic implications of advertising to the consumer and the professional? How will advertising affect the quality of services? Will advertising increase litigations? How will advertising be monitored and regulated to protect the public from false, fraudulent, misleading, and deceptive statements and practices?

It is urgent that the American College of Nurse-Midwives (ACNM), its members and nonmembers, explore in detail the issues of advertising by certified nurse-midwives and the ramification of these issues to nurse-midwifery and to consumers.

What is a certified nurse-midwife? What is nurse-midwifery practice? Where do nurse-midwives work? How can you find a nurse-midwife in your area? How do you become a certified nurse-midwife? Where is nurse-midwifery taught? Although these questions are raised and partially answered in the American College of Nurse-Midwives' publication, WHAT IS A NURSE-MIDWIFE?, there are few people in the United States and its territories in 1981, other than CNMs, who can answer some or all of these questions. The need for CNMs to increase their numbers, visibility, availability, accessibility, economic and political bases, and in fact their professional viability, is and has been a continuing source of concern to the ACNM's leadership, its members and non-members. These concerns have been formally identified in current and past issues of the Journal of Nurse-Midwifery and Quickening, ACNM convention speeches and workshops, and informally, among CNM colleagues.

In a 1971 editorial in the Bulletin of the American College of Nurse-Midwives, Mary Ann Iafolla, C.N.M., M.S. states,

“Nurse-midwifery cannot possibly have a significant impact upon maternal and infant care in this country until we have far more practitioners … Publicity — Public relations — Recruitment of prospective nurse-midwives—all these are essential to the growth, recognition and acceptance of our profession. Yet, here in the nation's Capital, nurses, doctors, and the lay public—virtually everyone—are unaware of the underlying ‘who, what, where, when and why’ of the contemporary nurse-midwife …”[2]

Linda Baxter, C.N.M., M.S. in a 1977 JNM editorial, “Survival Through Consumer Demand” comments,

“Few nurse-midwives could disagree with the premise that creating consumer demand should be a priority goal of the ACNM—But how to accomplish this task is the question. Consumer demand is based on consumer awareness of alternatives—itself based on the CNM's visibility and accessibility … How often each of us has heard: ‘Midwives … but, they don't exist anymore!’ We may feel reluctant to go out and sell ourselves or openly advertise; yet this may be what is needed for our survival. Not only is the public unaware of our role and function; they often don't even know that we exist!”[3]

Gail Sinquefield, C.N.M., M.S. in a 1979 JNM editorial writes,

“… what directions can we take that will maximize our impact on the American health-care system and best allow for our expansion both in numbers and in practice? With which forces must we align ourselves and which forces must we utilize to further the interests of our profession and of the health care of our clients? … How many consumers … are aware that such services are available through nurse-midwives or have access to nurse-midwifery care? Although the media recently has given some attention to the nurse-midwife, often we find that the scope of our practice is not recognized by the public. Clearly there is a need for further education of consumers as to the modern image and practice of the nurse-midwife … Each individual CNM and member of the College has an obligation to be an ambassador to the public for nurse-midwifery.”[4]

In a paper adapted from her presidential speech at the 1979 annual meeting of the ACNM, Helen Burst, C.N.M., M.S.N. states,

“This presentation has been entitled ‘What Price Visibility?’ as it addresses the most critical practicality and reality that the American College of Nurse-Midwives must confront immediately; of necessity our top priority. It involves the interrelated components of money, visibility, power, and volunteerism. In last year's Presidential Address, I stated that we were economically and politically naive, that the game was money and money was power, and that we had very little money and very little power … Running a professional organization takes money. Money buys not only membership services; it also buys visibility and power … to attain visibility one must be visible and to be visible costs money.”[5]

Each of these authors, other CNMs, and the ACNM's divisions and committees have articulated practical suggestions regarding ways the ACNM, its members and non-members, can increase consumers' awareness and demands for services. Some examples of the ACNMs many innovations include the hiring of a CNM government liaison, the activation of the Ad Hoc Committee on Consumer Affairs, The Ad Hoc Committee on Birth Alternatives, the Ad Hoc Task Force to the ACNM's Board on CNM—MD Relationships, the development of coalitions with consumer and professional support groups, and the development of a film, Daughters of Time,[6] about current trends in midwifery. The Publicity and Public Relations Committee has been particularly active during the past several years communicating about the ACNM and the CNM to consumers and professionals. Examples of its diverse activities are the Speakers Bureau, convention exhibits, the International Visitor's Hospitality Program, and the recruitment of nurses from minority groups into midwifery.* Other ACNM promotional activities in the planning stages include, e.g., the Ad Hoc Committee on Consumer Affairs's suggestions for a National Nurse-Midwifery Week in 1982, the development of a slide presentation on “What is a Nurse-Midwife?” and “What is the ACNM?” by the Publicity and Public Relations Committee, the publication of the ACNM's membership directory, and the publication of the Clinical Practice Committee's Registry of Nurse-Midwifery Services. In addition, the structural and functional mechanisms exist through the ACNM's divisions and committees to deal with the myriad issues involved in CNM advertising. Despite all of these activities, advertising by CNMs has not been as effective as most midwives would prefer.

How can one explain the fact that while most CNMs will readily contend that they are individually and collectively engaged in advertising themselves as CNMs and their functions, services, and activities to individual consumers, allied professional, and nonprofessional groups, a majority of consumers still do not know who the CNM is and what she does. Since presumably many of the uninformed consumers would elect midwifery services, the consumer's lack of information or misinformation about the availability of CNMs creates an artificially low demand for midwifery services. A low demand for midwifery services could be interpreted by physicians, third-party insurers, and legislators as a lack of public support for nurse-midwives. The reasons for the low demand could then become academic.

Nurse-midwives can no longer rely on the tenet that quality speaks for itself. Granted a satisfied consumer will increase volume by returning to the CNM for care and by attracting new clients through word-of-mouth recommendations. However, since many CNMs service a heterogeneous or a geographically scattered population, word-of-mouth endorsements are a slow and unreliable method to communicate with large numbers of potential clients.

What is an informed choice? How is it made? What information do consumers have, need, want, rate as important in the CNM selection process? Do consumers use the criteria they rate as most important when they select midwifery care as an alternative? Do consumers select a midwife and/or a midwifery service? How do consumers select midwifery care? Why do consumers return to the CNM and recommend her to others? How many consumers seek out CNMs for services other than obstetrical care?

Is it not time for the ACNM to survey its membership and consumers to determine what are people's attitudes toward advertising in general and by CNMs and other professionals specifically, toward the advertising of fees and services and the effects of advertising on each, and the effects of advertising on the availability, quality, and quantity of professional services? Is it not time for the ACNM to consider planning for a well-organized, intensive advertising campaign, including the hiring of an advertising/public relations consultant? Is it not time for the ACNM's committees to engage in money-making activities, the profits from which could be channeled into an advertising fund, a possible alternative to raising membership dues?

Nurse-midwifery is not only a profession but also a competitive business. The dichotomy between professionalism and commercialism, service and profit, cooperation and competition, is anachronistic in the 1980s health-care market place. Professionalism does not imply that one's services must be provided without adequate remuneration. Do not most professionals, especially women, disdain the suggestion that they are competitive individuals who are motivated by money as well as service to clients—a service orientation to clients is acceptable; a profit orientation is unacceptable and unfeminine? Are not midwives equally concerned about not only informing consumers about a high quality, lower cost alternative, midwifery, to traditional medical obstetrical and gynecological care, but also providing that care? Are not midwives equally concerned about their economic feasibility to society and midwifery's economic feasibility to themselves? Profit is not an incidental byproduct of service.

Whenever CNMs advertise they are both competing with physicians for a share of the market and trying to stimulate a demand for services that the physician can no longer provide at an acceptable cost. Would not a consumer go to a cheaper source of health care as long as quality is not compromised? A consumer's perception of the value of a service or skill is reflected in the amount she* is willing to pay for a standard service. Advertising by CNMs can clarify and narrow the perceptual gap between nurse-midwives' and physicians' delivery of standard services.

Inter- and intraprofessional rivalries are, also, an inevitable byproduct of competition. However, inter- and intradisciplinary interdependency in terms of medical and midwifery consultation, collaboration, referral, and collegial team relationships are not antithetical to professional competition. With the increasing proliferation of OB/GYN health care providers (e.g., lay-midwives, home birth attendants, OB/GYN nurse-practitioners) how can the public differentiate between these people and the CNM? How does each group define its uniqueness? How can consumers make choices among the variety of health-care providers when there is a lack of equivalency among people's education, skills, experience, responsibilities, and levels of practice? These differentials exaggerate interprofessional competitiveness among midwives. A beginning CNM practitioner may earn as much as an experienced midwife. CNMs who teach midwifery generally earn less than midwifery clinicians. Currently, there is much discussion about the “philosophical and practical implications of any change in title and education” of the CNM. Any change in title and education would further complicate the need to advertise differentials among midwifery practitioners. How will advertising affect our relationships with lay midwifery groups?

Since midwifery care is a cheaper alternative to physician care, an inevitable outcome of increased advertising will be an increased demand for midwifery services. An increased demand for services is not without its consequences. As consumer awareness of the functions, qualifications, and services of the CNM increases, the demand for services by CNMs will increase as will the need for more CNMs. As long as a scarcity of CNMs relative to demand for service exists, the price for midwifery services will increase, thereby generating more income for the CNM. The increased heterogeneity and volume of clients will create new and expanded demands for CNMs' services. Will existing services be able to absorb the greater client volume? Will education and refresher programs be able to handle more students? Will the ACNM's headquarters be able to handle the increased administrative load with its current staffing?


  • *

    Midwife/midwifery refers to certified nurse-midwife/nurse-midwifery practice as defined by the American College of Nurse-Midwives, 1978.

  • *

    The feminine pronoun she is used for the reader's convenience.

As consumer demand increases, physicians may want to form a partnership with a CNM, a choice economically advantageous to both them and the consumer. The CNM has a strong incentive to increase her caseload in order to minimize cost to herself and/or employer or partners at any given salary level. Idle time reduces income.

Since advertising generally lowers prices for services, some midwives may fear definition and comparison of fees and services. But since the CNM's income is low relative to the physician's and her services are cheaper, midwives should have little to fear from fee and service comparisons. Advertising and public relations costs are part of the cost of providing midwifery services. However, this cost can be borne by the midwife, the midwife's employer, interested consumers, and/or third parties responsible for paying for care. For example, if CNMs can document that midwifery services can lower costs to insurance carriers for standard services, presumably the carriers might be interested in informing their policy holders about the availability of midwifery services in an effort to lower their own costs. This type of publicity would be especially helpful as the cost of informing these potential clients would not be borne solely by the CNM or the CNM and her employer.

CNMs may not automatically realize the economic benefits from their advertising endeavors. Profits may go entirely to the employer, the party paying for the services, the CNM, or some combination. How the benefits are split depends on the bargaining position of the parties. If there is a large demand for midwifery services and not enough CNMs are available to provide the desired services, then the bargaining power of the CNM is strong. If the supply of CNMs increases faster than the demand, then the bargaining position of the employer is strong. If the CNM is in private practice the benefits are hers.

As volume increases, CNMs will have to develop new volume-related cost savings methods in their delivery of services: use of systems management techniques, task delegation via auxiliary personnel, substitution of capitol for labor.[7] CNMs must develop strategies for the planned increase in volume before the actual increase in volume occurs. Cost/benefit analysis of the CNM's use of time and services will be essential. If the volume of clients is increased while services are delivered in the same manner in an effort to reduce costs, quality may decrease.

Increased volume will lead to increased heterogeneity of clients seeking specific midwifery services; increase the need for differentiation of services; and create more opportunities for CNMs to develop subspecialities and expertise in certain areas. Subspecialization can reduce costs to consumers because repetition of a procedure or skill, increased knowledge and experience, and increased rationalization of a procedure decrease costs. The increased number of clients would improve the opportunity for CNMs to upgrade the value of their usual midwifery services with specialized services such as home births, biofeedback training, or genetic counseling. This should provide the CNM the opportunity to increase her salary or fees at the same time.

Additional ramifications of advertising by CNMs which must be considered are: As the volume and heterogeneity of midwifery clients increase, is there a greater chance CNMs will be involved in malpractice litigations? Will an emphasis on the uniqueness of midwifery from other professions, e.g., medicine and nursing, encourage the public to see the midwife as an independent practitioner? What are the advantages and disadvantages of individual versus group versus institutional advertising? How will CNMs, especially new midwifery graduates, in solo or small group practices compete with larger midwifery services who, presumably, will have larger advertising budgets? Could the disparity in advertising budgets be a barrier to CNMs who want to establish a private practice? Will CNMs find it more profitable to enter group practices? Could CNMs institute a class action suit against those who restrict consumer access to midwives?

It is imperative that the American College of Nurse-Midwives consider the implementation of the following recommendations:

  • 1Poll the ACNM's membership to determine individual's attitudes about advertising by professionals in general and advertising by nurse-midwives specifically;
  • 2Activate a standing Committee on Professional Ethics and Advertising to develop liberal ethical guidelines on advertising by CNMs; establish an Ad Hoc Grievance Committee to handle violations of the ethical guidelines; monitor trends and developments in advertising by CNMs and other professionals; facilitate and coordinate the advertising efforts of CNMs and ACNM's committees; educate CNMs and student nurse-midwives about advertising theory and techniques via continuing education programs and workshops; coordinate its activities with the Publicity and Public Relations Committee, the Ad Hoc Committee on Consumer Affairs, the Professional Affairs Committee, and the Division of Publications;
  • 3Hire a part-time advertising/public relations consultant;
  • 4Increase the advertising budgets of the ACNM's divisions and committees, especially the Division of Publications, the Publicity and Public Affairs Committee, the Professional Affairs Committee, and the Ad Hoc Committee on Consumer Affairs;
  • 5Hold an open forum at the 1982 ACNM convention to discuss the issues and ramifications of advertising to midwives and the midwifery profession;
  • 6Conduct a multidisciplinary workshop on professional advertising at the 1982 ACNM convention;
  • 7Participate in FTC and legislative hearings investigating constraints on midwifery practice;
  • 8Sponsor a multidisciplinary meeting with ACNM's coalition groups to identify the need for the support of these groups to assist CNMs' advertising efforts and to encourage these groups to intensify their efforts to promote midwifery.

Advertising has advantages for the midwife and the consumer. Advertising by CNMs increases the public's awareness of, demand for, and access to a high quality, lower cost alternative to traditional medical obstetrical and gynecological care. Providing clients with information so they can make informed choices is part of the traditions of midwifery. Increased demand for midwifery services will mean growth of the profession and enhancement of the individual midwife's status and economic compensation.

We regret to announce the death of Catherine Sheckler, an ACNM founder and early pioneer of Nurse-Midwifery.