Growing the Midwifery Workforce
by Kate Woeber PhD, CNM, MPH
Join us on Thursday February 15th for the next GA ACNM affiliate meeting where Kate will be discussing this topic!
Relevance of midwifery workforce to health outcomes
The increasing shortage and maldistribution of primary care, reproductive health providers have serious adverse effects on health in both high- and low-resource countries. In the U.S. in 2016, over half of primary care service areas had no obstetrician-gynecologists, CNMs, or CMs.1 In developing countries, currently only half of pregnant women receive the recommended minimum of four antenatal care visits.2-4 Worldwide, 140 million women lack access to desired family planning measures. And while advances in care have generally improved the health of women and newborns worldwide over the past decades, 2016 still saw 830 women and 7,000 newborns deaths each day 5 The U.S. has been highlighted as an exception when it comes to maternal-child health; ours is the only developed country with an increasing maternal mortality, partly driven by our shameful racial disparities in maternal-child health access and outcomes.2,6-10
In The Lancet’s 2015 series on Midwifery, the potential impact of scaling up midwifery services was estimated to be the most effective means of reducing maternal, fetal, and neonatal deaths worldwide. One of the most profound figures reported in the 2014 Lancet Series on Midwifery estimates that 61% of maternal, fetal, and newborn deaths could have been prevented by universal access to midwifery care.11-15 Unfortunately, the shortage of reproductive health providers, even in the US, is worsening. The U.S. Department of Health and Human Services projects that by 2025, the national deficit of reproductive health providers will be over 4,900 obstetrician-gynecologists, 2,000 CNM/CMs, 1,650 women’s health nurse practitioners, and 1,150 women’s health physician assistants.16 At at time when the U.S. Census Bureau projects a 14% increase in the number of births per year by 2060, the physician shortage continues to worsen due to increased obstetrician-gynecologist specialization, fewer residency programs, provider retirement and burnout, and an increasing proportion of female obstetrician-gynecologists, who are more likely to work part time and to stop attending births at a younger age.17,18
Active management of the reproductive health workforce scale-up is imperative, and given the midwifery workforce’s proven track record of efficient training (midwifery training is associated with roughly one-quarter of the time and cost of the training of obstetrician-gynecologists), and effective caregiving (our maternal and newborn outcomes are at least equivalent, our patient satisfaction is higher, and our cost of care is lower when compared with outcomes and costs of care given by obstetrician-gynecologists), it makes sense to focus substantial and strategic efforts on the training and workforce retention of midwives.19 This effort begins with well-defined goals, such as those drawn from three key ACNM documents from 2015: an issue brief, “Domains of Inquiry for Research Studies on the CNM/CM Workforce”, the Midwifery Education Trends Report, and the Diversification and Inclusion (D/I) Task Force report, “Shifting the frame: A report on diversity and inclusion in the American College of Nurse-Midwives“.20-22
Midwifery Education and Workforce Survey
With an eye on ACNM’s goals (as interpreted below), the “Midwifery Education and Workforce Survey” (MEW Survey) was developed and distributed during the fall of 2016 to investigate the educational and workforce experiences, as well as the workforce plans, of approximately 240 early-career CNMs (within 5 years of initial certification). Respondents were from 42 U.S. states, the District of Columbia, 1 U.S. territory, and 1 international location (not specified). Graduates represented thirty-eight of the 39 U.S. midwifery educational programs, with the greatest participation from Frontier (22.7% of respondents), Emory (12.5%), Vanderbilt (9.4%), and Yale (7.4%) universities. 2/3 of respondents had been employed as RNs for at least one year prior to enrollment in a midwifery education program. Of those, 62% had worked as labor and delivery RNs for over 2 years, 9% worked as labor and delivery RNs for 1-2 years, and the rest had worked as RNs outside of labor and delivery (many worked as RNs in and out of labor and delivery). Prior certification as a lactation consultant, doula, health educator, specialized RN (RNC), social worker, massage therapist, or similar was reported by only 11.5% of the respondents.
Midwives of color accounted for nearly 12% of respondents, which is lower than the estimated 22% of the recent cohorts of newly certified CNMs/CMs.21,23 Some of the main results are below.
ACNM Goals and Survey Results
ACNM Goal: Gather current, basic workforce data focused on workforce.
- 85% of respondents work full-time (at least 35 hours per week).
- About half have salaries between $75K and $99K. Those whose salaries are more than that are most likely to work in private practice, and those whose salaries are below that are most likely to work in out-of-hospital settings.
- As far as work setting, the largest percentage work in private practice (36%), and the smallest percentage work in out-of-hospital settings (12%). About 19% work in low-resource settings, and the rest work in a variety of other settings, such as educational institutions, federal government and military, or HMO or hospital-based sites.
- Most CNMs provide antepartum, intrapartum, postpartum, and well-woman care. About 63% also provide primary care, and about 23% are also responsible for newborn care.
- When comparing those with and without prior RN employment, those who worked as RNs are more likely to work full-time, but they have shorter workforce potential (they are an average of 6 years older than those without prior RN employment).
- When comparing midwives of color with white midwives, midwives of color are more likely to practice full-scope midwifery (including primary care and newborn).
ACNM Goal: Establish and increase the capacity of midwifery educational programs to graduate 1,000 students per year (from the 583 who graduated in 2014)21,24,25.
- About ½ (53%) attended midwifery programs that were mostly or fully online.
- Most attended midwifery school full-time (69%) and most completed a single major (71%).
- Most students attended at least 30 births (90%), most reported satisfactory performance throughout their programs (89%), and almost all passed the certification exam on their first try (95%).
- 2/3 had loans of at least $50,000 to finance their midwifery education. The rest had either no loans or loans under $50,000.
- Almost half had no scholarships or grants, and 18% had a scholarship or grant over $25,000. Midwives of color are less likely to have a scholarship or grant, but they are more likely to have the larger awards, over $25,000.
- CNMs with prior RN employment were more likely to have completed an online program, to have studied part-time, and to have completed a single major. Regardless of prior RN experience, midwives reported high levels of mentorship from faculty or preceptors, and no differences between groups in measures of academic or clinical performance during school. Both groups had the same first-attempt pass rate on the AMCB certification exam.
- Midwifery students of color were more likely than their white counterparts to complete a dual major or degree, less likely to have attended at least 30 births as students, and less likely to agree that their educational program was supportive of their culture.
ACNM Goal: Characterize and optimize factors related to workforce retention, such as work incentives and professional relationships.
- Several scales that correlate with a variety of outcomes—job satisfaction, organizational and/or career commitment, and individual performance—were used to ask midwives about their impressions regarding work performance and about the ongoing suitability of the profession for their lives: Occupational Self-Efficacy, Personal Outcome Expectations, and Perceptions of Empowerment in Midwifery. Midwives’ ratings on these scales were high, averaging at least 3.75 out of 5. Scores did not differ by prior RN employment. Midwives of color scored higher on personal outcome expectations, and lower in their agreement with the statement “the midwifery profession is a good fit for my culture.”
- Many factors affect whether a CNM has a stronger sense of having adequate skills and resources at work: grit, attending an online midwifery program, attending at least 30 births as a student, satisfactory academic and clinical performance as a student, having a moderate amount of school loans, having a scholarship to finance midwifery school, and full-scope practice.
- Midwives’ agreement with the statement “I am satisfied with the amount I am currently paid for my work as a midwife” (scale was strongly disagree=1 to strongly agree=5) were lower, with median score 3 out of 5. The only predictor of satisfaction was actual salary.
- Almost half (45.5%) of midwives have changed jobs at least once since certification, and about 30% plan to remain with their current employer for the next 5 years. Midwives were more likely to plan to remain with their current employer if they did not have prior RN employment, if they did not have larger scholarships or grants to pay for school, and if they had higher personal outcome expectations. The top 2 reasons for seeking another position were for better hours or higher salary. Planned moves were away from private practice and low-resource settings, and towards out-of-hospital and educational settings.
- 87% of midwives plan to precept midwifery students in the future. The strongest predictor of this was the midwives’ sense of having adequate skills and resources at work.
- Midwives’ future career plans were not different by prior RN employment. Midwives of color were less likely to have changed jobs, but their future career plans were not different from those of white midwives.
Summary of midwifery education and workforce survey data
- Educational program innovations are doing a good job of accommodating students regardless of whether they’ve worked as RNs.
- Prior RN employment is not important for success in midwifery education.
- Minority students may not be experiencing equivalent clinical opportunities or cultural support.
- Further exploration of the optimal use and amount of scholarships and loans is needed.
- Midwives’ perspectives about their work are positive regardless of work setting.
- Prior RN work experience does not determine midwives’ job satisfaction, organizational and/or career commitment, individual performance, or career plans.
- Midwives with and without prior RN employment both benefit the workforce, although those with prior RN experience have shorter career potential and possibly more employment mobility.
- Midwives of color may perceive less inclusion in the midwifery workforce.
- Salary is a factor influencing recruitment and stability.
WHAT YOU CAN DO TO HELP BUILD THE MIDWIFERY WORKFORCE:
- PRECEPT!!! Clinical sites are the major bottleneck for training more midwives. If your busy practice can accommodate more than 1 student at a time, offer to do it! If you can precept one student for a couple of months, that would be great also!
- Communicate with the programs whose students you precept. What would make your work as a preceptor more manageable? What kind of precepting schedule would help prevent burnout?
- Students, faculty, and administrators: Thank a preceptor! And let’s find more ways to build mutually beneficial partnerships between academia and clinical settings, particularly those clinical settings not formally associated with academic centers.
- Legislative advocacy: Medical residencies are subsidized by the federal government at a rate of $100,000 per OB/GYN resident, compared with expenditures that equal about $25 per student midwife (no, there are no zeroes!)… This legislative session in Georgia, House Bill 301—Preceptor Tax Incentive Program (PTIP)—allows for Physician Assistants and APRNs (not just physicians) to serve as preceptors and receive a tax credit for such service. Also consider the effect that full practice authority (Senate Bill 351) might have on the retention of midwives in the workforce.
- Recruit employer support: Make workforce part of the conversations you have with your employers. How can your employer support/reward your dedication to precepting? How can they ensure that you have the resources you need, so that you will have time and space to accommodate a student at your practice?
- Researchers: To correct structural barriers to professional inclusion, the midwifery profession requires a thorough understanding of how the academic and clinical experiences of URM and non-minority midwifery students differ, as well as. Let me know if you’d like to collaborate!
- Know what your market value is, and advocate for the salary, benefits, and hours that you a midwife should have, and that will contribute to your career longevity.
- What are your ideas? Reach out to us via social media or email!
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