“Direct entry” of non-nurses into the midwifery profession is an issue that has created polarization among CNMs. Nurse-midwives are all too familiar with being excluded and have little desire to exhibit exclusionary behavior toward any other group struggling for legitimacy. Therefore, it is reasonable to expect that the profession would respond to proposals for alternative entry routes in a positive way. Support of this concept is difficult for some, however, because terms, definitions, and language keep changing for that undefined number of practitioners called lay midwives, independent midwives, apprentice midwives, direct-entry midwives, empirical midwives, or birth attendants. This issue has become further complicated by an onslaught of state legislation that often omits any reference to educational requirements, delegates to physicians the responsibility for the education and supervision of midwives, and threatens to eliminate the legal base for nurse-midwives by establishing boards of midwifery that potentially could become controlled by lay midwives.
The Carnegie Foundation has facilitated a series of meetings of an Interorganizational Workgroup on Midwifery Education with the stated purpose of promoting “midwifery through the development of alternative educational routes to the profession.” This group of 18, with equal representation from the American College of Nurse-Midwives (ACNM), the Midwives Alliance of North America (MANA), and consumer advocates, recently drafted the Scope of Practice, Standards and Qualifications and Legal Recognition for a “Professional Midwife.” Ostensibly, this proposed generic midwife will be prepared for practice by routes approved by MANA or ACNM and will practice according to the standards of MANA or ACNM. It appears, however, that one standard of practice has not been achieved to date.
These efforts notwithstanding, it is still not clear why nurse-midwives are engaged in such an energy-consuming exercise at this critical time … unless it is the intent of some for MANA to subsume the ACNM. If, on the other hand, the motive is to promote the growth of midwifery, should nurse-midwives not be seizing the opportunity to expand the already established route to midwifery immediately being sought by more than 4,000 nurses? There is no one else to address this need. The 65-year record for quality midwifery care in this country was largely achieved by the nurse-midwives who established a foundation for education and practice that now has an unprecedented potential for exponential growth. In fact, a goal of 10,000 new nurse-midwives by 2001 was enthusiastically endorsed by the attendees at the 1991 ACNM convention in Minneapolis. This resolution is not a pipe dream. It is attainable. But, it will not happen without a concentrated effort from all nurse-midwives and the continued support of educational programs provided by grants and scholarships from nursing.
Those who advocate direct entry often reason that nursing is an inappropriate prerequisite for midwifery and has been a barrier to the development of midwifery as an independent profession. The claim is that the “sick model” is the wrong approach to care of well women; that nurse-midwifery has been co-opted by the medical model of high-risk, high-tech care; and that direct entry is the model for the future development of the profession.
Those who advocate for nurse-midwifery reason that nursing is an appropriate requisite, though not necessarily a prerequisite. Their rationale includes the perspective of Mary Breckinridge who, upon thorough investigation of the qualifications and scope of practice of American nurses, French midwives, and the combined preparation of the British nurse-midwife, decided that the public health nurse-midwife would best meet the needs of childbearing women and their families. She did not coin the phrase “family-centered maternity care,” she just implemented it. The focus of the nurse-midwife on the family, not just the pregnancy and birth, is a major factor in support of nursing as an integral part of any midwifery education. The need for every midwife to be able to interface with both the health and sickness systems with intelligence and understanding is another factor. Perhaps a more important consideration is the midwife herself. Let's assume that we all agree that formal education for the profession at a postsecondary level is a sine qua non and that a large component of nursing should be included in any direct-entry curriculum and that the program of study will lead to a bachelor's degree in midwifery. How much more would be required to round out the curriculum, similar to Yale University's model, so that the graduate would have multiple career options and employment opportunities that would include nursing? How would you counsel your daughter or son?
The question is not whether direct entry is a viable route to midwifery. We know that direct entry is feasible. Yale has demonstrated it at the graduate level. Nurse-midwives have contributed a large measure of support to the Seattle School in Washington State. A little-known fact is that a large percentage of the students from that program are nurses. This should have told us that we needed to become pro-active in opening and expanding nurse-midwifery education. Nurse-midwifery has not generally supported the “see one, do one, teach one” approach of some apprentice programs.
The question for this moment is whether it is advisable to drain the limited energy of nurse-midwives and the dwindling available educational dollars to embark on a new venture. If we address the need for service providers in rural and urban underserved areas, the well-prepared public health nurse-midwife would seem to be the preferred provider. If we address the needs of hospital practice, we should perhaps be talking about taking all the closet midwives in nursing out of the closet. If we address the desires of foreign-trained midwives who need to add the nursing component, Ruth Lubic has suggested to our nursing colleagues that a “fast track” for preparation in nursing be developed. If we address the desires of diploma and ADN nurses, as the faculty at Case Western Reserve University Frances Payne Bolton School of Nursing is now doing, perhaps we can open up the present on-campus track to an MSN and CNM in a community-based model.
To date, more than 4,000 nurses have requested information or applications to CNEP alone; in addition, the enrollment in its third class (the first nonpilot class) has been exponentially increased to 80 students for this fall. Other programs are also reporting unprecedented numbers of nurses seeking entry to the profession. Clearly, the “window of opportunity is wide open” for nurse-midwifery. The possibilities are endless; but, which has the greatest potential for success now … at this time? How long will this window be open? How will we as a profession respond? Should we rally all of our energy and resources to respond to this ready market of nurses and those entering nursing to become mid-wives? Or, should we divide our energy and resources and try also to develop alternative paths to midwifery that will, of necessity, include a heavy component of nursing while not enabling the graduate to practice nursing when in a “midwifery-dry” jurisdiction.
In a recently published article entitled “Nurse-Midwifery: The Window is Wide Open,” Judith Rooks laments that “nurse-midwives have been fighting an uphill battle for decades. Now when their excellence has finally been recognized, their numbers are too small” (1). The window of opportunity referred to by Rooks is open to nurse-midwives now. What, then, has the greatest potential for success? My vote is for all the leadership in nurse-midwifery education and practice to rally all of our energy and resources to prepare those 10,000 nurse-midwives by 2001. Those who have gone before us tested the model and organized the profession for this window of opportunity. Do we not owe it to them, to the nurses who have long waited for the opportunity, to the women and families who seek our care, to the system that seeks our help, and, last but not least, to ourselves?