The World Health Organization (WHO) has designated 2020 the Year of the Nurse and Midwife, commemorating both the 200th anniversary of Florence Nightingale's birth and the work of nurses and midwives globally. Several national and international initiatives this year seek to raise their profile, including the highly anticipated release of the first State of the World's Nursing report on April 7 (World Health Day), the publication of the National Academy of Medicine's Future of Nursing 2020-2030 report in the fall, and the final year of the Nursing Now campaign, a collaboration between the WHO and the International Council of Nurses (ICN) to improve the status of nurses worldwide. The third State of the World's Midwifery report is expected to be released next year.
Elizabeth Iro, the WHO's chief nursing officer, says these initiatives will “highlight the contributions nurses and midwives make in helping to achieve global health targets.” Efforts during the next year, she says, will focus on ensuring these health care providers are part of policymaking within their own countries, as well as regionally and globally, and raising awareness of the need for investing in their empowerment.
UNIVERSAL HEALTH COVERAGE
Nurses make up the largest segment of the U.S. health care workforce, and nurses and midwives together account for nearly 50% of the world's health workforce. Growing and empowering these professions is essential to the WHO's primary goal of achieving universal health coverage. At least half the world's population lacks full coverage of essential health services, according to the WHO, and all member states of the United Nations (UN) have pledged to work toward achieving universal health coverage in the next decade.
Nurses and midwives are also vital to achieving the UN Sustainable Development Goals (SDGs). The WHO estimates that an additional 9 million nurses and midwives must be recruited by 2030 to achieve SDG 3—Good Health and Well-Being—in all countries. Improving the status of these health providers—the far majority of whom are women—also has the potential to improve gender equity and economic development, which are the focus of other SDGs.
“The WHO's focus on nursing provides opportunities to increase understanding of nurses' value—globally and here in the United States—which the ANA hopes will spur expanded investment in education, practice, and research, as well as increase the number of nurses who serve in leadership positions,” says Ernest Grant, PhD, RN, FAAN, president of the American Nurses Association (ANA).
COMPLEMENTARY ROLES IN THE COMMUNITY
The inclusion of both nurses and midwives in the 2020 designation is a reminder of the overlap in health services they provide and in their professional identities, which have developed differently in each country. “U.S. nurses may not be aware that in many other countries, nursing and midwifery are separate professions,” observed Pam Cipriano, PhD, RN, FAAN, dean of the University of Virginia School of Nursing in Charlottesville, past president of the ANA, and current first vice president of the ICN. “Midwives are critical primary care providers in many communities beyond our borders.”
The services provided by nurses and midwives include health promotion, disease prevention, emergency care, and education and counseling. Because they tend to practice in the primary care and community settings, where most people seek treatment throughout their lifetimes, these providers care for a large part of the population and fill a central role in the community. Their services are also essential to guaranteeing the reproductive rights of women and girls.
The State of the World's Midwifery 2014 report concluded that midwives who've met international educational and regulation standards can provide 87% of women and newborns' essential care, which includes sexual, reproductive, maternal, and newborn health services. Most midwives' scope of practice includes the provision of a range of essential and preventive health services throughout a woman's lifetime, not just during pregnancy and birth care. The midwifery model of care differs significantly from the medical model, most noticeably in that midwives regard pregnancy and birth as natural processes, not as medical conditions that must be managed and require intervention. They monitor a woman's physical needs, as well as her psychological and social well-being, avoiding unnecessary interventions and encouraging women to participate in their health care decisions.
Educating midwives to international standards improves care and reduces maternal, perinatal, and infant mortality rates, leading to improvements in more than 50 outcomes, according to a recently published WHO report, Strengthening Quality Midwifery Education for Universal Health Coverage 2030. This ranges from an increased uptake in breastfeeding and immunization to a reduction in newborn crying and postpartum depression and cesarean section rates. Yet, there's a lack of investment in quality midwifery education globally, particularly in low- and middle-income countries, according to the findings. “In order to attain universal health coverage, in order to have quality sexual and reproductive care, we need midwifery education to be strengthened,” said Emmanuelle Hébert, MSc, professor of midwifery at the University of Quebec at Trois-Rivières, former president of the Canadian Association of Midwives, and current International Confederation of Midwives' board member. Speaking at a side event to the UN General Assembly meeting in September 2019, “Power on the Path to UHC 2030,” she added, “There's a lack of skilled educators, a lack of midwifery training materials, and a lack of good placement for midwives.”
The immediate need for improved and accessible maternal care is clear. Although the global maternal mortality rate has steadily fallen in the past 30 years, an estimated 300,000 women continue to die annually as a result of pregnancy or childbirth complications. Many of these deaths, some of which go unreported, are due to preventable causes. The vast majority occur in lower-income countries, but women continue to die unnecessarily everywhere. The Centers for Disease Control and Prevention (CDC) estimates that of the 700 pregnancy-related deaths annually in the United States, three out of five are preventable. “Midwives,” Hébert said, “are a crucial part of the solution.”
MIDWIFERY IN THE UNITED STATES
Although midwives in many similarly developed countries attend a majority of births, U.S. midwives attend only about 9% of births. A considerable majority of these midwives are certified nurse midwives (CNMs) attending hospital births, according to the CDC.
The role of midwives in the United States is poorly understood—even among other health care providers—owing to a complicated mixture of cultural, economic, political, racial, ethnic, and gender issues dating to the 19th century, when medicine was professionalized and health care institutionalized. Midwives, who had varying levels of skill and training, traditionally attended all births in their communities. By the 1800s, as physicians sought to expand their practice and the use of new interventions, they encouraged women to give birth in hospitals under their care. The maternal mortality rates rose during this period and persisted through the 1930s, as documented by physician and medical historian Irvine Loudon, among others, who attributed this to the medical care the women received and the spread of Streptococcus pyogenes in these facilities. Despite this, the medicalization of childbirth continued, leading to a significant decline in traditional midwifery in much of the United States during the early 20th century, at which point most remaining midwives practiced in immigrant, indigenous, and African American communities. When Mary Breckinridge established the Frontier Nursing Service in 1925 in eastern Kentucky's Appalachian Mountains—followed soon after by the founding of the Frontier Graduate School of Midwifery, which continues today (as the Frontier Nursing University)—she employed RNs who also had midwifery training, so they could care for rural women and their families.
Nurse midwifery has since become the dominant U.S. midwifery model. CNMs are licensed, independent primary care providers who can practice and prescribe in all 50 states, the District of Columbia, and U.S. territories. By contrast, certified midwives (CMs) receive the same level of midwifery education but are not nurses and are only authorized to practice in six states (they can prescribe in three of these), according to the American College of Nurse-Midwives. Both can provide care in all settings, although most attend hospital births. Since 2010, a graduate degree has been required for entry into practice. Other midwifery providers in the United States include certified professional midwives (CPMs), who are not required to have an academic degree for entry into practice and attend births mostly outside of hospitals. As of October 1, 2019, 35 states license or regulate CPMs, according to the Midwives Alliance of North America. Traditional or lay midwives similarly practice in homes or birth centers but aren't certified or licensed nationally (although some states have requirements for education and licensing).
Most private insurance covers midwifery care provided by CNMs and CMs. Medicaid reimbursement for care provided by CNMs is mandatory in all states—only three states require such reimbursement for CMs—and they are reimbursed at 100% of physician rates in most of these programs. Six states mandate private insurance to cover the cost of care provided by CPMs, who are included in the Medicaid plans of 13 states.
This patchwork of certification and reimbursement regulation has led to misperceptions about the profession and barriers to midwifery access. “It adds to the confusion, even among nurses, about the work midwives do,” says Felina Ortiz, DNP, RN, CNM, a clinician educator and assistant professor at the University of New Mexico College of Nursing in Albuquerque. Ortiz helps to recruit and support students and midwives of color, who have historically been underrepresented in nurse midwifery. “It would make a huge difference to recruit more nurses and midwives from our underserved communities, who would then help to serve these communities,” she says.
This is particularly important given the United States' most pressing health challenges, which include a lack of access to hospitals and obstetric facilities and maternal and infant mortality rates that disproportionately impact underserved racial and ethnic groups. Researchers who examined the integration of midwives across the United States found fewer adverse neonatal outcomes, higher rates of natural birth, and a reduction in costly obstetric interventions in areas where midwives had been better integrated into interdisciplinary teams and health systems, according to a 2018 study in PLoS One.
INVESTING IN NURSES AND MIDWIVES
Midwives and nurses currently lack powerful voices in policymaking and decisions about the allocation of health care resources. Nurses “are not often tapped to contribute their expertise to high-level conversations or critical decision-making groups that are determining the future of health care,” Cipriano told AJN. The Year of the Nurse and Midwife, she said, offers a chance “to showcase the critical role nurses play in improving access to health care for people everywhere. It is a call for countries to recognize and address shortages of these professionals and invest in preparing nurses to effect a rapid, cost-effective scaling up of high-quality care.”
Speaking at the UN side event in September, Leslie Mancuso, PhD, RN, FAAN, president and chief executive officer of Jhpiego, an international health organization affiliated with Johns Hopkins University in Baltimore, Maryland, noted the need for action. “We're getting the world's attention, so now it's our time to act and unlock the power and potential of nurses and midwives to be decision makers and leaders in the community,” she said. “Building a robust nursing and midwifery workforce in order to meet universal health care demands is not going to happen by chance. It's going to happen when we invest.” This requires, she added, building networks of nurses and midwives, providing them with appropriate financial compensation, advocating for gender parity in educational institutions and health facilities, and ensuring their participation in multidisciplinary teams.
Iro notes that the State of the World's Nursing report will be presented and discussed at several global health meetings in the coming months, providing “opportunities to amplify the message about leadership and influence and investment.” In addition, she says, U.S. nurses can make key contributions to global health efforts this year by highlighting their advanced practice nursing roles and achievements. “There are positive outcomes they can show, in terms of their contributions and in the role areas that nurses are covering. I hope to see countries sharing their positive experiences and the differences they're making.”
Nurses and midwives can also take advantage of the opportunity afforded by the Year of the Nurse and Midwife to connect with colleagues globally, said Cipriano. It's “a time of celebration, to spotlight Florence Nightingale's legacy and her influence, which still inspires the nursing profession globally today. We are more alike than different, so the fact that this is a global designation should be embraced by U.S. nurses as a move toward solidarity and mutual support for our colleagues around the world.”—Corinne McSpedon, senior editor