Last year I did a small mini series on the state of midwifery in the United States and the obstacles ahead for the profession. It wasn’t meant to start a spirited debate, but to bring to light facts and numbers that speak for themselves. It is only when we all acknowledge the facts that we can truly start working towards a common goal. I find that most people don’t have a good idea of where midwifery stands in the United States, or more importantly, where midwifery has the potential to go! But I would also argue that the COVID-19 pandemic highlighted the potential and the benefits of midwifery across the nation.
Many of the facts from the series last year haven’t changed – and if anything – the pipelines for midwifery training were at a standstill for most of the year. Many students lost sites and preceptors. Many schools had to push clinical start dates for students. It was a rough year.
If you missed last year’s series, in the fall of 2019, the ACNM (American College of Nurse Midwives) and the ACME (Accreditation for Midwifery Education) published a report titled “Midwifery Education Trends Report – 2019“. The report highlighted the current state of the road to midwifery and also the long road ahead. If you’re curious, there were also reports published in 2011, 2013, and 2015 (access them here). This was the best summary on the midwifery force that I was able to find and an updated version has yet to be published.
The three part series starts with a review of where the workforce stands and the long road ahead to making more midwives. This year, part 2 is aimed at bolstering the midwifery workforce (with shout outs to some midwives doing awesome work across the nation) and part 3 is aimed at advocating for midwifery!
Let’s dive in.
How many delivering providers work in the United States?
As of August 2019, the number of CNMs (certified nurse midwives) and CMs (certified midwives) was 12,655 and 111, respectively. In contrast, there were 33,624 OB/GYNs in 2010. That’s 3 times as many OB/GYNs as midwives. For comparison, OB/GYNs compromise only 5% of the 661,400 physicians in the United States (American College of Nurse Midwives [ACNM] & Accreditation for Midwifery Education [ACME], 2019).
At the time of this writing, I wasn’t able to find a current number for practicing CPMs (certified professional midwives) in the United States but was able to confirm with the North American Registry of Midwives (NARM, Debbie Pulley, 2020) that they have issued a total of 3,693 certifications since the credential was certified in 1994. Ms. Pulley was unable to say how many CPMs are actively practicing. On NARM’s website in 2020, they listed that 3,850 certificates have been administered since 1994 and they look to reach 4,000 in the year 2021.
Do we need more midwives? What’s the predicted economic outlook (for jobs and money) for midwives?
The future is bright! And yes, we need more midwives. As cited in the report: “According to the Bureau of Labor Statistics, the overall employment of nurse midwives is projected to grow 26% between 2018 and 2028, much faster than the average for all occupations. As of May 2018, the Bureau reported the mean annual wage of a certified nurse-midwife at $103,774 annually” (ACNM & ACME, p. 10, 2019). The median annual salary for a CPM is estimated at $54,201 (source).
So, how do we graduate more midwives?
Alas, that is a multi-faceted answer. Let’s start with the good news. There are more than 500 CNM/CMs passing the midwifery exam each year! It’s hard to say how many of these individuals are going directly into practice, but the numbers are moving in the right direction. Additionally, NARM certifies a few hundred CPMs each year.
First, the pipeline into midwifery is a bit of a bumpy road. What does that mean? To start, midwifery schools are not easily accessible and many states don’t even offer a midwifery program.
The 2019 report summarizes the main idea: “Despite the compelling need for more midwives to enter the workforce, there has been no growth in the number of ACME accredited midwifery education programs between 2009 and 2018″ (ACNM & ACME, p. 5). For my own training, I moved from Texas to Colorado to attend my midwifery program.
Second, maximizing student enrollment in the available midwifery programs continues to be a problem. Let’s take 2018 for example. In 2018, approximately 2,000 individuals applied for candidacy into a midwifery program, approximately 1,000 individuals were accepted, and 123 spots were unfilled (ACNM & ACME, 2019). The average for vacant program spots from 2014 to 2018 was 135 students annually (ACNM & ACME, 2019).
Over a ten year period, that’s almost 1,000 students that could have started midwifery school! So, why are there so many vacant spots?
“Midwifery education program directors provided ACME with reasons for not reaching capacity which included insufficient qualified applicants, limited clinical sites and preceptors, and
applicants accepting positions in other midwifery programs” (ACNM & ACME, p. 6, 2019).
The problem isn’t just vacant spots. It’s also finding someone to teach students the art of midwiery. Midwives practice in all 50 states, but that doesn’t mean finding a preceptor is easy.
“Midwifery program directors consistently indicate that they could increase graduation rates if more clinical sites and preceptors were available for midwifery students” (ACNM & ACME, p. 10, 2019).
Regardless of the barriers, the number of graduates is slowly but surely increasing each year.
How do you grow the midwifery workforce?
The 2019 report states that “direct funding for midwifery education has been identified by the ACNM as the number one priority for growing the midwifery workforce” (ACNM & ACME, p. 10). Aside from this priority, there are 6 additional recommendations to grow the force (and an extra one that I added!).
Recommendation #1: Increase the number of ACME-accredited midwifery programs.
The report breaks this recommendation into smaller recommendations: invest in midwifery education in the 24 states that currently do not have midwifery programs, or in areas where maternal mortality is high and the number of CM/CNMs is low. I don’t know anything about starting a school for midwifery, but I can imagine that it’s a hefty to do. That being said, it doesn’t make sense to have 4 programs in some states and no programs in other states. The other consideration is that midwifery programs must have spots for their students to complete clinicals – for those that don’t know, on average, a midwifery student does around 1,000 clinical hours in their training. Many other students are competing for that same clinical spot and community hospitals or birth centers only have so many clinical spots at a time. Additionally, OB/GYN residencies play a major part as well in the availability of spots in a community.
I don’t have a lot of wisdom for this recommendation, but I can say this: going forward in your practice, career or pregnancy, keep in mind that where you choose to spend your healthcare dollars matters. If you choose midwifery, you are increasing the demand in the economy for a service that you want. If there is enough demand (and money), that creates a greater demand in a community or state. If you want to move the needle for midwifery programs, start by choosing midwives where ever possible.
Recommendation #2: Support and increase federal, state and private funding.
This recommendation is broken down into two separate recommendations: first, to increase federal funding for midwifery programs in a fashion similar to how OBGYN training programs are funded, and to encourage private donors or foundations to specifically support midwifery education or programs.
How do you increase federal and state funding? You GET INVOLVED! Write a letter to your congressman…ask them to support midwifery and bills aimed at increasing midwifery autonomy and education. I used to work with a midwife that would send a postcard to her Congressman for every baby she delivered. She would include the same simple message: “Congressman, you have a new constituent!”
Our government is by the people, for the people; don’t give up before you even try to contact the people that are sitting in the seats making decisions. Can you imagine what would happen if every midwife in the United States sent a postcard to their Congressman for each baby they delivered? What kind of response would we get (and how amazing would that be!)?
Recommendation #3: Full practice authority in all 50 states.
Did you know that states that allow autonomous practice for CNMs have lower cesarean rates, preterm birth rates, and low birth weights than states without autonomous CNM practice (Tony Yang, Attanasio, & Kozhimannil, 2016)? Full practice authority is a no brainer.
This one is self explanatory – but for those that are a little confused, can you imagine going to the doctor and after the doctor diagnoses you they tell you they can’t write you a prescription…or give you a certain type of medical equipment you need…all because of their state regulations? Many nurse practitioners face this exact issue in their practice every day. Midwifery is no different. If you’re not sure where your state stands, I encourage you go to the Board of Nursing website for your state and read the scope of practice. I personally read the scope of practice every time I renew my nursing and midwifery licenses – to me, it’s just a good habit to see what has changed in the past 2 years. It also illuminates what changes still need to happen for full practice authority – or, for more autonomous practice.
Recommendation #4: Equal pay.
Equal pay doesn’t mean that midwives should make what an OB/GYN does! It means that midwives should be reimbursed the exact same as the OB/GYN when performing pregnancy care or a vaginal birth. In Alaska, Medicaid only reimburses 85% of what a physician is reimbursed. In a hypothetical situation, if a physician is reimbursed $1000.00 for a vaginal delivery, the midwife is only reimbursed $850.00 for performing the same skill and procedure.
If you know anything about Medicare and Medicaid, know that these are federally funded programs. The annual reimbursements published by these entities guide much of the healthcare reimbursement in the United States. If you are a midwife or a midwifery student, start learning about these concepts sooner rather than later. And again, this is a great thing to address in a letter to your legislator.
Recommendation #5: Interprofessional education.
The report recommends increasing models that support midwifery education and strengthen the maternity care workforce. One of the most thought provoking podcasts I listened to this past year was an interview with Hilary Schlinger. She spoke about the fields of nursing and midwifery and brought up some interesting points about both professions. One of my favorite takeaways was this: Why don’t we have Departments of Midwifery just like there are Departments of Obstetrics? It was such a profound thought – but then I thought, why don’t we?
We have to start integrating midwives into OB/GYN residencies across the country. Midwives are experts in normal birth and are perfectly positioned to teach normal birth to medical students, 1st year residents, physician assistants, emergency workers…you name it. We’re experts in normal birth, it’s time to put “midwifery in the models.”
Recommendation #6: Diversify the workforce.
Lastly, the report mentions increasing the diversity of the midwifery workforce. There are studies that have demonstrated that patients are more likely to comply and complete recommended care from an individual of their own ethnicity or race. Midwifery is no different, we need more diversity.
A Final Recommendation: Advocate for midwifery as the standard of care.
Okay, this recommendation is my own!
Here’s what I love about standards – they’re simple and easy to remember. In the United States, the maternity healthcare system is fragmented and fractured. There is so much to improve and midwives are capable, trained professionals perfectly positioned to fill the gaps and bring improvement to women and children across the nation. It’s time to accept and expect that midwifery care is available to every woman and to move towards a place where midwifery is the standard of care for maternity care in the United States. The simple act of advocacy will help achieve each of the six recommendations – it only takes one act at a time.
Whew. That’s a heavy list of recommendations. The good news is that the work is worth doing. Awareness is the first step – if any of this information is new to you, please take it to heart and keep an ear to the ground in your state. Help where you can. Support where you can’t.
See you guys next week for Part 2!
American College of Nurse Midwives & Accreditation for Midwifery Education. (2019). “Midwifery Education Trends Report – 2019“, 1-13.