NURSE-MIDWLFERY CARE TO V!JLNERABLE POPULATIONS Phase I: Demographic Characteristics of the National CNM Sample

Anne Scupholme, INM, MPH, Jeanne DeJoseph, CNM, PhD, FAXN, Donna M. Strobino, PhD, and Lisa L. Paine, CNM, D~PH, FAAN

ABSTRACT The purpose of t:,;i anicle is to describe the etient to which cef!%ed ““rS‘-mldwiy.:s ICNM5) provide care to winereble papulation~ in the “niled Sfates and the MU,CPot reimbursement for thb care. The data were obtainedfrom the iirst pheseal a nat$~,~l study to addres Me chare&erisScs of women sewed and costof care provided& CNMs. Resultrwere analyzednationallyand by AmericanCollegeof Nurse-Mldwws wgfons.CemRednurse-midwives in al typesof pmcltcesare protidm$;careto women from population. that are vulnerablelo poser then averageo”tcomesof childbirth beeawe of age,soc+oeconomic statue,refugeeslatus,and ethnicity.N,r.etywne percent of CNMe report sewing at tear one grout of vainerablewomen. ar.d CNMs in the inner city and mral practicesseive severe,grotips The vast mejo,ttr af CNMs are salaried:on,,, 11% receiveuleir plimey incomehorn fee-fa-&ce Fifty percen,of the payment for CNM servicesis born Medicaid and government-subsidized forces whereaslessthan 20% comesfrom privateinsurance.Sourceof incomevariesby typs of seM”gIn which the CNM attendsbibs. The resultsm~est !he! CNMs. ai a group, makea major conhtbutionto the care of vulnerablepopulations.

Nurse-midwives have sewed vulnerable populations of mothers and babies in the United States for decades II, 2). Indeed, several mdtes have reported high quality and cost-effective maternity cafe provided by nurselnidwiw lo pregnantwxnen who are cdo!eecent,poor, of refugee status,or who have language baniers (3-9). There are, “evertkie%, no national data on the amount oi care provided by nurse-midwives to women from vulnerable populations, the chamcteatics of these wonx?“, the setting5 in which they receive nurse-midwtfeycare.ortheflrE&ngoftheircare. The purpose of this article is to repa*

findings from the Rrstphase of a project designed to obtain these national data. Recommendations ,kom a 1985 study of the banters to nurse-midwifery care included the need to document the conhibutions of nurse mtdwiw to the care of vulnerable populations (101. Further support for the current study aroes from the deliberations of a focus group of health care policymakers and nurse-midwives. convened by the American College of Nurse-Midwives (ACNM) in January 1991 lo address the wed for data about nurse-midwifery care provided to vulnerable women. This information was needed for health policy de&tons regarding the proposed changesin Medicare/Medicaid reimbursements This stxdy, “Nurse-

Midwifery Care to Vulnerable Pop ulations,” was designed to obt&n prospect% information about the women and babies who are cared for by nurse-midwives and the cost of protidtn3 these srrvices. The study was funded by the Robert Wood Johnson Foundation through the ACNM Foundation. Incorpamted. METmlDS Data for the first phase of the study, reported in this article. were cokcted throwh a one-page q”&on”dre dewei&ed by the research team with assistance from expelts in health p01icy, economics, and demography. To the extent pwsible. the questionnatre was designed to result in data that ax!dbecomparedMthftmLingfmm

Anne Scupholme.CNM.MPH.is the chief

nurse.midwi~eotJockson Memorial Hospiti, Miami.Florida and an adjund nrsoaotep,o,esw,,obstehics and gynecolwy.Onivemityof MiamiSchool ofMe&“e. She ir (1board member of

the ACNMDiuisio”

of REswmh and

PmjedM.“a~r,orLhecurre”tACNMRWJ~searchpmject “Nurse-MIdwiley Coreto Vulnemble Popuhtionr.“Her rerewchendocodemic interests hclude hmhhpolicyissuesconcerning occezto healthcareandcliniceliravesre,“ti”gto lowbirth weight JeanneLkbseph, c.w cssistant,,m,~orarthe

POD,FAIIN, is on Unbern’ty of

Col$omio. San Fmncisco, and Cm

Director oftheMidwifeyPrcgmm, Departmentof FamilyHealth Core Nws;.ing, ““iuersity af Colifomio,San Fmncisco.She b Challpersonof the

Pmfernonaf Deuelopment Committee of theAClVMDivisio”ofResearch and a

minuesti~,oro,,hecunentACNMRWJrewrchproject, “Nume-Mldulfey Core to Vulnembfe Populations.“Her teseomh and academic interests include the women’s v,o*duti”gpreg”o”cya”d

socblcuppo”intewentiions omang Afica”.Americo”preg”a”two”,e”.

DonnoM. Shobino.pho,iranars~iote proferor, DepartmentoJMatenmiand ChildHealth, Schljol ofHyaeneand PublicHea’th, Johns Ho?kins University, Bohimore Maylond. She is D

coi”ves&torfcrtheACNM-RWJ resarch gmnt,“Nurse-M!dwfey Core to VulnemblePopubtio”s.“Herreseorrh i”ler&.soree”d”tio” ofpetfmal prcgmmsandeemicer, d&efopme”tof risk aswwnent ir&ume”ts. andthe impact of life-styleand demogmphic jnctors 0” plegnoncy olaco”Ie.5 LisnL &i”5=, swl OPH, :4.4x, 8s”” orxnmeprofessorandDirectoralthe Nurse-Midwifely of theB&onUniwsit~~, SehcalofPubk Health, B&on, Mawchwelts. Shetsik ChoirgerJonoftheACNMDiuisionof Research ondPro,ectDirectorforthe ACNM-RWJ reroarh gmnt, “NurseCue to VulnemblePopularions.“Her-rchintereslsarelow technolagyfaalassssmentend health policyissuesregarding nurse-midwifery pmcticeond maemoland child health.

previous surveys and former ACNM survey techniques. This questionnaire was deslgned to answer questionsabout the-generalcharacteristics of the c&Red nurse-midwife ICNMI careghm. locations of practice, and vulnerable population groups sewed. A pilot study of the questionnaire wee conductedin May 1991 among“unemidwives who are members of the ACNM Service Directors Network. Modifications I” the date collection forms were made based on this pilot study. Approval for the study was obtained from the Research Sub]ect.s CommIttee on Human Research, Johns HopLns Univenity. School of Hygiene and Public Health, Baltimore, Man/land. The eampbngframe included4,303 perso~l~listed in thz general ACNM data bank in Mav 1991. This ACNM list contains the ‘&nes of all people who have ever applied for cetifkalion or who were sesaciatemembers of the ACNM. Sixty-seven percent were alea listed in the 1990 ACNM membership directory. Although the ACNM databankcontainedthe names of people who mtqht not aualifv for pa&&ion in thi etudy, i wei the most comprehensive lit availablefor Salllpli”g. A one-page questionnaire and a cover letter explaining the purpoea of the study were sent to eachperson on the 9eneral ACNM data bank list. A self-addressed, stamped envelope was enclosedand all two!& were en-

turned, 39 were duplicate questionnaires, four were returned by relatives of deceased nurse-midwives, seven were returned by femily members of people in other camtiles, and 225 had been se”t to persons who were “ever certified as nurse-midwives, Of the 2.405 eligiblenurse-midwiw who returned the questionnaires. 1,804 (75%) were members of ACNM. Forty-six percent of the “onrespondents I” = 744) were ACNM members. The sutvev~ were returned behveen July Ii91 and October 1991. Every U.S. state except Nebraska is represented. (At the time of the data collection the mailing list did not indude anyone tram Nebraska.) The response variecl from a low of 45% in Indiana to a high of 88% in Hawaii. The -“se rate ranctedfrom 57% to 67% iA 34 (68%) &es and the District of Columbia. The rewonse ratewar greaterthan 80% in three states and was less than 50% in three other states. Table 1 shows the response rate by the 1989 ACNM regional boundaries. The auatlonnaire included items on the demographiccharacteristicsof the women that nurse-midwives served. pr&ice sites, and the sources of payment for services (see Appendix Al. A checklist format was used to determine whether the nurse-midwives served a”y members of the follOwi,&? groups: adolescents, AfrtcanAmericanrblack women, H&panics, relum the qkstio”nalre Asia”s/F’&ic Islanders. Native immediately. Of the 4.303 questionAmaicans. miglantsi”mltgQnts, poor rains mailed, 2,655 were re‘ehrmed women, and uninsured women. Rewithin hvo months after the initial spondents were also asked to provide mailing, for a response rate of 61%. information on sites used to provide A postcard reminder wzyj sent to the ambulatory care and labor and delii1,648 nonrespondents with instmcey careof their &en& and to indicate twx to contact a research team what percentage of their clients live member if they had never recetved in four c&go& of urban and rural the questionnaire. Only 25 responses settings. The items on various sources resulted from tho second mailing. A of payment for services required a total of 2,680 questiLon”aireswele repercentageresponse. tumedinthefirrtandse~ndmaiungs The questionnaire asked for inforfor a” overall response rate of 62.2%. mation about the percentageof work Of the 2,680 questionnaires retime spent in active clinical pradice,

couraged to

EducotionPmgmm

Midwifery

rate

years of practice as a nurse-midtife, age, and source of income payment. Validation was requested &the respondent was actuallv a CNM. Further questions asked hr the approximate number of clients seen each week and the state, county, and zip code of prachce. These data u,ere required to select a sample of nursemidwives whose service p~pulaiion will be more intensively studied during the second phase of the project and provide prospective information about the type of service provided and the cost of that care. Data from the second phase are currently being collected and will be described in subsequent articles. ihe date from the returned questionnaires were entered into dBASE Ill + cleaned and edited, and anaIyredusingTrueEpistat (11). Theentiredata set was analyzed as a whole and a separate analysis of data was done for each ACNM @on. Table 1 shows the stiltes in each region as defined bv ACNM in 1989. The definitions were used for the pulposes of ‘hi study:

TABLE 1 Participation in the Survey by ACNM Regions*

I (NoTtheast. n = 913)

567 ,62%,

Vulnemble populations are defined as popukticms that are likely to expelience poorer tian average outcomes of pregnancy by tiltlle of their age, race/etbnicity. financial status, geogmphic IocaBan, and immigmntlmigmnt status FtESULTS Of the 2,405 04rn respondents to the survey, 526 (22%) were not h dnical mact!ceand 1.879 178561were in clinical practice. The dnical pmclice group, (goup II, 1s the focus of this report The gmup not in clinical practice. group I, is desctibed briefly only in terms of demographic charactedstics and current employment status.

Connecticut, Delaware.

13.5

Massachusetts. New Hampshire. Pennsylvania.Rhode Island, Vermont. Virqinia. WestVirgina New Jersey.New York

II IEast: ” = 572, 111 (Sathew n = 7361

356 ,62%,

1”

410 (62%)

15.6

331

12.6

Cenhal.

” = 6631



,5o”lhwfs~

” = 664)

176

,59%) 19 1

Diedci of Coliimbia. Maine. Manjland,

Alabama. “orida. Gear~a. Mississippi. Nonh Carolina. South Carolina,Tennessee IUinois.Indiana. Iowa. Kentucky.Michigan. Minnesota.Miuoun. North Dakota.Sauth Dakos. Ohio. Wixonsin Adzana.Arkaansas. Colorado. Kansas.Loui*ana. Mon,ana. New Mexico,OWahoma.Tees. Utah. Wyoming A!askc California Hawaii Idaho.‘Nevada.dregon.

Washmgtan

Total n = 4.303

1ml-J

2.630

fc&uhg

A CNM is an individual educated in the two discfplfnescf nursing and midwffew. who ws~ssses evi-

216

-

Group I-Nurse-Midwives Not in Uinical Practice (n = 526) The mean age of the nurse-midwives who were not in clinical practice was 47.4 years, with a range of 25 to 83 years. Although not in clinical practice now, they had practiced as nursemidwives for an average of 7.8 years. Fifty--Rue (10.5%) had never practiced nurse-midwifery, although they had been certtfied. Over half of the 526 respondents in this group were not workx~s 133.4%). retued 1183%l. or partof the work force because of postgraduateeducation or full-time motherhood (7.9%). However, some members of thii group indicated that they were in full-time nurse-midwifey administration (3.6%) or nursemidwifery education (3.6%) even though they were not active in clinical practice. The remaining 33.2% were

not

emuloved in lobs related to nudna (13:3%) or public health (3 2%) ; had other twes of careers 116.721. The remainder of the data reported here are obtained from the reports of 1,879 CNMs in clinical practice. Group II-Nurse-Midwives in Clinical Practice (81 = 1,879) The mean age of nurse-midwives in clinical practice was 41.2 years, with a range from 25 to 75 years. They had been in practice for an average of 8.4 years, with a range from 0.2 to 53.5 years. On average they spent 84% of their work week in clinical pmaice, 6.0% in admj&t&m, 4.5% in nursemidwifery education. and 5.5% in other nurse-midwiferywelated activities.Eighty-nine percent of the nurse-midwivesin clinical practice (n = 1.674) get more than 50% of

343

their tncome in the form of a salary. Nine percent (n = 165) receive50% or more of their income from professional fees: 2% (n = 20) get most of their income from other sources. Populations wtth Vulnerable Characteristics Served bv CNMs in Clinical Practice

Fifty-SIX percent ofwomen

who are cared for by nurse-mldwtves live in areas that are designated as unders-w&d. either the inner city or rural areas. The geographicdistribution of women sewed by CNMs varies significantly among the ACNM re@ons (Table 2). Certified nurse-midwives in NewYork and NewJersey (Region II) serve the greatest percentage of inner-city residents, whereas CNMs in the Southeast and Southwest serve thegreates:percentagesofwomen living in rural areas. AU groups of women that were defined as wlnerable to less than average health care for lhls study were served by nurse-midwives Of the CNM respondents. 99% sewe at one group of wcmwn and over 80% serve women with five or more vulnemble characterktta. The percentages shown were computed in r&t.. lion to all survey respondentsin active clinical practice.Re@x~al differences in the charact&tics of women served by CNMs reflect regional population differences (Table 3). For example, the greatestpercentageof CNMs who repottedserving Native Americanslive in the Southwest or West. ACNM Rcgions V and VI.

least

Settings for Ambulatory and Delivery Services Because respondents ivere asked to indicateall s&ngs that appliedto their practice, and many worked In more than one setting, the percentagesums exceed ?oO%. The data on ambulatory practtcesettings are presented nationally and by region in Table 4. Certified nurse-midwives were most likely to practice in hospital clinics, private off&s, and public clinics; 10% or less provtded ambulatory care in health maintenance organizations IHMOs) or birth centers. There was some variation by region. A greate: percentwe of CNMs in the Northeast iRegton i) worked in pxivateoffices, whereas pubhc dInice were reported as more freouent oracticesites in the Southeast (F&i& 111) and Southwest (Region VI. Region II (New Yorkand New Jersey) had the greatest percentageof CNM.s who provided ambulatoy care in hospitals. It is uncommon for CNMs in Regions II and Ill to practicein HMOs and for CNMe in Region N to practice in birth ten-

ten. Eighty percent of the CNMs who deliver babies do so in hospitals (Table 4). Only 191 of :hem (10.2%) deliver babies in out-of-hospital birth centers. When the data for this study were collected there were 115 free standing birth centers in operation in the United States (personal communication, Eunice K. Ernst March 1992). There were significant regtonaldifferences in the proportion of CNMs attending births in the free-

TABLE 2 Percentaw of Women Srrved bv CNMs bv Area of Residence Urban

Art?0 ACNM

Suburben

fV

f%J

17.5

26.9

region

I

33.7

Ii

56.2 29.5 34.2 27.9 24.3

13.1 17.0 20.6 20.9 22.3

33.7

18.6

::: iv ;I

lwional

21.9

20.6 26.4 27.5 28.7 18.9

10.1 27.1 17.7 32.3 24.2

26.4

22.3

366 (1WJ 264 (100) 219 376 (loo) (1001 I.879 UC0

standing birth centers. The wjon

with the highest percentage was the huthwest; the lowest percenegewas in the Central region. Seven percent of the CNMs (n = 132) had home birth pratices; the dishibution differed slgniRcnnhy among ACNM reglans. ,he highest percentages of CNMswith home birth practiceswere in the Northeast and Southwest; the Southeast had the lowest percentage. Table 5 shows the percentage of CNMs who serve vulnerable pop”IaLion groups by type of birth setting in which they practtce.Certified nurse midwives in practices that include home births serve more rural women and fewer inner-city residenk as compared with CNMs who deliver in birth centers or hospitals. Certified nursemidwives who deliver babies in ho+ pit& were more likely than those using other childbirth settings to serve inner-city women and most othervulnerable groups as well. The percentage sewtng adolescenk, blacks, Asians, Hispanics, and immtgmnt women is !avest for CNMs with home birth practices. However. CNMs with home birth pratices were most likely to be sewing women without insurance. sources of Income Sixtynine percent of the respondent CNMs reported that part of their income came from Medicaid sources. On a national average,about 40% of reimbursement for CNM services comes from Medicaid, 19% from health care insurance, and 15% from HMOs. Sources of reimbursement varied by region (Table 6). Certified nurse-midwives in the Northeast rely more heavily on Medlcaldas a source of reimbursement compared with CNMs from other regions Certified nurse-midwives in the Southeast provide more free care than CNMs elsewhere. Certified nurse-midwives’ income from HMOs Is geakst in the NorUw&, the Centi region, and ihe West. Table 5 shows considerable variation in the source of reimburse-

Vol. 37, No. 5. SeptemberiOaober 1993

TABLE 3 Percentages of CN:Vr; Serving Vulnerable Populations by Type of Population and ACNM Region

forthei;own of reimbursement for CNMs with home birth practices; they contrtbute least to the income of CNMs in hospital settings. The reverse I.5hue for Medicaid as a source of reimbursement is a greater M”nx of reimbursement for CNMs in pmctices that include births in birth centers and home births.

Insurance

DISCUSSION Since the first national ACNM suwey wa conducizdin 1963 thew !I& been a gradual increase and change in the chamctedsti of nurr-midties, their oracticea and the women they serve. ilw ACl’iM survey conducteda 1?63 showed that 31% of nune-midwives werein clinical practice (13). in 1991. 72% of respondents were in clinical pm&e. This trend is supported by fromnational repolts of births attended by norsemidwives. The National Center for Health Statisticsesttmatedthat 1.8% of aii births in the United States in 1982 were attended by midwives in hospital, as compared with 3.3% in 1989 being attendedby CNMsinatypesof bit settings(14, 151. This figure indicate5 asutitiinaeare werseve”y-aE. The resoits of our study indicate that a lxge percentage of practtcklg nurse-midwives serve women from winembte groups. Women were de-

information

Rned as vulnerable in our study if they were poor, adolewent, part of a mlnortty ethnic group, of immigrant status, oriivingin medically undersewed xeas. The results indicate tnat 99% of all respondents serve at least one group of vulnerable u~omen, and CNMs saving the inner city and mm1 popuhtions provided services to wx”en with several of these charxtetics Many studies (l-9) have validated the quailiy of care give” by nurse-mthuives to women with these characteristics, indicating that their outcoI”es of pregnancy often are poorer than the national average. and demonstrating the improvement in outcomes that have been directly attributable to CNM care. Thirty-four percent of the women cared for by the nurse-midwives in this study live in innercity areas;22% of other women live in rural areas. Our findings differ from a recent gotemment report 116). based on a limited eempldof CNMs (n = 542). that stated that onk 11% of CNMs have a practice in mml settings.The same report stated that only 1.5% of CNMs delivered babies at home, whereas the results of this study indicate that 7% are attending home births and 39% of women who are delivered at home by nurse-midwives liw in mmi areas. iddttiorml research is need+xl to understand the contribution that nurse-midwives in home birth practices make to the care of women in

rural areas, .w well as to the care of uninsured women. The philosophy of nuw-midwifery pmcttce has a+w.=ays stressed the independent ma~gement of childbearing families. However, 89% of the respondents repated that they receive their income in the form of a s&y, whereas only % reported that they received the majodty of their income from professional fees These results are co”&e”t with data from a recent repat from the Olfice of the lmpeaor General (16) sog@jng that the majotity of nurse-midwives are workins as em”!ooees. whether in co”ju”&on .&?thphystciam or as an employee of an agency. Gver 50% of the reimbursement for CNM care is&her from federal or state fundina whereas only 18.9% of their income comes from commercial health care i”swmce. There is great vatition behvxn+hestatwforexampie,insome stat-. suchas Fkxida, the percentage of imxme from public funds for care give” by CNMs is eve: 60% (unpubItshed data from this study). Our studv has two limitations that wanant comment here. The first is the 62% raspollse rate to the suvey, and the fact that the chamcterishTsof the “onrespondents are unknown. The response rate is likely underestimated. It was “ecessav to we the genemi comprehensive data base of the ACNM for our sampling frame rather than the cunent membership

_

345

TABLE 4 Settings for Ambulatory by ACNM

and ChildbIrth

Services:

Percentages

of CNMs

Practlclng in Each Setting

Region

semng

Ambulatory saing Hospital clinic Public clinic Pdvale office He&h maintenance Opp”l2a@O” Birth CCP+T

NaKlnal ,n _ 1,379,

Rfqion 1

Nurse-midwifery care to vulnerable populations. Phase I: Demographic characteristics of the National CNM Sample.

The purpose of this article is to describe the extent to which certified nurse-midwives (CNMs) provide care to vulnerable populations in the United St...
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