• Sally S. Cohen PhD, RN, FAAN, Assistant Professor and Director,

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    • Sally S. Cohen is assistant professor and director of the Center for Health Policy at Yale University School of Nursing. Her recent research and publications focus on the arrangements between advanced-practice nurses and managed care organizations. She is also writing a book on the politics of federal child care legislation. Dr. Cohen has been director of Public Policy and Research for the National League for Nursing, and she has extensive experience in state and federal social policies, especially as they pertain to children and families.

  • Deanne R. Williams CNM, MS, FACNM

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    • Deanne R. Williams is Executive Director of the American College of Nurse-Midwives. Prior to assuming this position, she worked as Director of Services for ACNM. She is active in influencing policy development in relation to women's health care and midwifery practice. Her nurse-midwifery education and master's degree were earned at the University of Utah. In 1994, she was chosen as a U.S. Public Health Service Primary Care Policy Fellow, and she serves as an editorial consultant to the Journal of Nurse-Midwifery.

  • CNMs/CMs and midwives as used herein refer to those midwifery practitioners who are certified by the American College of Nurse-Midwives (ACNM) or the ACNM Certification Council, Inc.; midwifery refers to the profession as practiced in accordance with the standards promulgated by the ACNM. The formal mechanism recognizing the CM credential began in 1996; thus, CMs are not included in federal Medicaid or Medicare laws or regulations nor in some HMO/MCO provider lists.

  • In this article, the terms health maintenance organization (HMO) and managed care organization (MCO) are used interchangeably.

Center for Health Policy, Yale University School of Nursing, P.O. Box 9740, 100 Church Street South, New Haven, CT 06536-0740.


Managed care poses special challenges to midwives providing reproductive health care. This is owing to the sensitive nature of issues surrounding reproductive health and aspects of managed care that may impede a woman's ability to obtain continuous, confidential, and comprehensive care from the provider of her choice. Variations across payers (ie, Medicare, Medicaid, and commercial insurers) regarding covered benefits and reimbursement of midwifery services also may create obstacles. Furthermore, some physicians and managed care organizations are embracing policies that threaten the ability of midwives to function as primary health care providers for women. Despite these hurdles, midwives have the potential to remain competitive in the new marketplace. This article underscores the importance of being knowledgeable about legislation and policy issues surrounding the financing of midwifery services, quality performance measurement for HMOs as they pertain to reproductive health, and discussions regarding which clinicians should be defined as primary care providers.