Nurse-Midwifery Care Settings
CNM/CM Practice/Employment Settings
Pang Yuhao
Affiliated Hospitals
Hospitals where CNMs are employed can be university hospitals associated with medical schools, private teaching hospitals, community hospitals, government hospitals, military hospitals, or critical access hospitals.
Hospital Owned Midwifery Practice
Typically, a hospital-owned midwifery practice is physically structured so that there is dedicated office space, either in the hospital, itself, or on hospital grounds, where the midwifery practice can care for their patients. Care provided for patients can be primary care, prenatal, postpartum, well-woman gynecology, and family planning care.
Certain religion-based institutions will not allow family planning care or counseling within their institutions. However, CNMs are adept at supporting natural family planning and counsel, as their employing entity may support.
CNM Practice Structure
The CNM practice will, generally, care for their own patient population within a clinic setting and will deliver their patients in the employing hospital. The CNMs/CMs are the employees of the hospital and the nurse-midwifery practice will be administered in the clinic and hospital by hospital administrative and managerial staff. The midwives in this environment will not typically have independent decision-making authority regarding their compensation, hours, policies, procedures, or other administrative practices.
CNM Practice Leads
While the midwifery practice, itself, may have a designated “lead midwife” or “practice coordinator”, most important decisions on all aspects of practice are overseen by hospital administration and, only infrequently, will a designated lead midwife have any significant administrative power or authority in this setting.
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Physician Collaboration
Physician collaboration can occur in a variety of ways depending on the institution. If the hospital is associated with a medical school or an OB residency training program, the collaborating physicians for the midwives will, typically, be the faculty attending physicians. While the employed nurse-midwives may be expected to “consult and collaborate” with the OB resident physicians of a certain level or year, this varies across the country. Occasionally, nurse-midwifery practices are associated with Family Medicine residency programs or private physicians from the community, but this association is rare due to the fact that the association of family physicians has indicated that they do not support midwifery care. *
Hospital Owned Midwifery Practice
Some hospital-owned nurse-midwifery practices are not associated with resident training programs and the hospitals where they are based may employ OB attending physicians to provide collaborative support. Most often, this type of arrangement is associated with independent Hospitalist and Laborist groups who will provide 24/7 call coverage for the hospital’s labor and delivery unit. Certain hospitalist groups will, also, provide triage services for unscheduled patients who appear for evaluation.
Teaching Hospitals vs. Private Hospital CNM Practice
Consistent with teaching hospitals, the private hospital nurse-midwifery practice is usually owned and operated by the facility or one of its clinics. There are national Hospitalist Obstetrical Groups that directly employ certified nurse-midwives. These CNMs, and the physicians hired into these groups, must complete a credentialing process and be appointed to the medical staff of the hospital where the Hospitalist team has contracted to provide services.
While hospital CNM/CM practice environments may vary, hospital administrations typically wield a heavy hand in the running of a nurse-midwifery practice. Unfortunately for prospective maternity clients, administrative care decisions and nurse-midwifery availability, autonomy, and compensation are usually made based on hospital corporate financial considerations rather than to support quality midwifery care for the benefit of the consumer.
A variation of the hospital-owned, employee nurse-midwifery practice is a situation where individual obstetrical practices are hospital-owned and within these practices hospital-owned CNMs/CMs are planted to take care of the OB practice patients or develop a caseload of their own. The owner/hospital has total control in running these combined practices along with supervising the conduct, relationship and responsibilities of everyone.
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Practice In Rural Areas
In isolated rural settings with limited healthcare personnel and hospital services, nurse-midwives may be found independently practicing; providing primary, antepartum, delivery, postpartum, and newborn services for all patients presenting to the hospital for care. Care may be provided in conjunction with OB or Family Medicine collaboration which is local but may, by necessity, span specialty providers at several health care centers in a specified region.
In some situations, CNM consultation may involve communicating with OB specialty providers who are hundreds of miles away. Determination of patient acuity, triage, referral or emergent transfer by ambulance, helicopter, or fixed-wing aircraft may be up to the nurse-midwife and an off-site consultant who is willing to accept the transfer. These situations sometimes require calls to more than one acute-care hospital in the region. These special care situations in critical access hospitals will vary across the country but the nurse-midwives are generally employed by, or contracted by, the hospital or health care service that administers the facility.
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