The nurse-midwifery program in New York is described, and an overview of the past decade is presented. The possible contribution of the nurse- midwife to the personnel needs in obstetrics is discussed. Incentives are needed to stimulate use of nurse-midwives. NURSE-MIDWIFERY IN NEW YORK CITY David Harris, M.D., M.P.H., F.A.P.H.A.; Edwin F. Daily, M.D., F.A.P.H.A.; and Dorothea M. Lang, R.N., C.N.M., M.P.H. Introduction nursing-since 1931 the minimal re- quirement of the nurse-midwife candi- THE health role under discussion was date has been that she be a graduate conceived, in New York City at least, nurse-and from obstetrics, the disci- in the 1920s1; the gestation period pline that equips her to perform her lasted almost 40 years. Despite the an- special skills. cient roots attributed to the role, a brief historical survey should convince one of Obstetrical Care Provided Under the legitimacy of labeling Nurse-Mid- Medical Direction wifery a new health role. The first school for nurse-midwifery In contrast to her European counter- in New York City was established in part, the American nurse-midwife al- 1931 by the Maternity Center Associa- ways functions within a medically di- tion.2 However, it was not until 1959 rected health, service. She is part of the that the city formally recognized that obstetrical team. Since she is never an the incumbent in the role of midwife independent practitioner, the ultimate had substantially changed. Licensure ex- responsibility for the patient continues clusively for nurse-midwives was estab- to rest with the medical staff.6 lished in New York City in that year- just ten years ago. Graduates of nurse- Historical Background midwifery trained in the preceding 29 years were licensed under a health code The Old-Style "Granny" Midwife that had functioned to empower their The Old Style "granny" midwife nonmedically trained professional an- flourished in New York City during the cestors. The Health Code Amendment first decade of this century; over 40 per of 1959 denied legality for the practice cent of the babies born in New York of midwifery to all but the nurse-mid- City in 1905 were delivered by these wife, except for the two or three remain- empirically trained practitioners.7 The ing "granny" midwife permittees.3'4 extensiveness of the use of midwives The contemporary nurse-midwife role engendered a public health concem, in the United States derives from three since their licensing did not test their sources: midwifery, nursing, and ob- qualifications and their practices were stetrics. The role derives only culturally essentially unmonitored. from that of the "granny" midwife.5 In 1907, midwives came under the Professionally, the role emerges from jurisdiction of the Board of Health. Ef- u VOL. 61, NO. 1, A.J.P.H. NURSE-MIDWIFERY IN NEW YORK CITY forts to standardize the practice cul- its doors to the nurse-midwife; in 1955, minated in 1914 in the requirement that that hospital involved itself in the edu- an applicant for a midwife permit be cation of the nurse-midwife through an a graduate of a school for midwifery. affiliation with the Maternity Center As- Despite these efforts to influence the sociation.10 The municipal hospital sys- care rendered by old-style granny mid- tem joined in the education of the wives, there was increasing pressure nurse-midwife in 1958 with an affilia- from health planners to improve the tion between Kings County Hospital and quality of obstetrical services in New the Maternity Center Association. Per- York City. The pioneers of nurse-mid- haps a correlate of this involvement is wifery recognized that the logical re- the fact that licensure of the nurse- cipient of this force for change was midwife was introduced in New York nursing.1 City one year later. The concept of associating midwifery and trained nurses dates back to 1881. Licensure for Nurse-Midwives It was then that Florence Nightingale In 1960, the first permits to practice said she considered midwifery a serv- nurse-midwifery in New York City were ice "women should offer women."8 The issued to five nurse-midwives.11 proposal that midwifery be a specialty for graduate nurses was presented at a Nurse-Midwifery Service Programs meeting of the National Association of Accepted into Hospitals and Public Health Nurses as far back as Health Department 1912.9 Implementation was painfully slow. In 1961, the Department of Hospitals created a new professional line, that of Education in Nurse-Midwifery the nurse-midwife; the first nurse-mid- The first organized attempt to train wives to practice in hospitals in New the new professional in the United States York City joined the obstetrical teams occurred in New York in 1923. The at Kings County and Cumberland plans were not realized. It took a demon- Hospitals. stration project, rather than an educa- Three years later, in 1964, Roosevelt tional one, to bring nurse-midwifery to Hospital became the first voluntary hos- fruition.1 In 1925, the Frontier Nurs- pital to utilize the services of a nurse- ing Service employed the first nurse- midwife. In 1968, the Department of midwives in the mountain counties of Health, specifically the Maternity and Kentucky. New York City, however, can Infant Care (MIC) Projects, employed boast of having established the first the first professional with the title school of nurse-midwifery in the na- of nurse-midwife. Since then, 11 nurse- tion.2 And appropriately so, since recog- midwives recruited by the Depart- nition of the concept of midwifery and ment of Health have joined the obstet- the responsibility for its standardiza- rical teams in hospitals with which MIC tion had early precedence here. is affiliated. These same nurse-midwives function in the Health Department Com- Nurse-Midwifery Education Programs munity Maternity Centers. Accepted into Hospitals Entrance into the organized system Nurse-Midwifery Manpower in of medical care did not occur until 21 New York City years after the first nurse-midwives were The number of nurse-midwifery per- graduated in 1934. Columbia-Presbyter- mits that were issued by the Depart- ian-Sloan Hospital was the first to open ment of Health of the City of New York JANUARY, 1971 65 Table 1-New CNM permits issued, after Table 2 and Figure 2 show the actual May 1, 1960 number of CNMs holding permits each year. After the initial total of 5 permits 1960 5 for the year 1960, the figure demon- 1961 11 strates a yearly increase which con- 1962 9 tinues through 1968 when 67 CNMs 1963 5 were issued permits between May 1, 1964 16 1968, and April 30, 1969."1 1965 15 Educational Preparation for Nurse- 1966 14 Midwifery in the United States 1967 12 1968 17 Educational preparation for nurse- midwifery is offered in nine schools which are approved by the American College of Nurse-Midwives. A certifi- has varied from year to year. Table 1 cate in nurse-mnidwifery is offered upon and Figure 1 show the actual numnber completion of an 8-, 12- or 24-month of new permits that were issued to course. The longer programs offer a Certified Nurse-Midwives since 1960.1" master's degree with the Certificate of There was a sharp rise from 1963 Nurse-Midwifery." 12 through 1964. The slight drop after 1964 A Certified Nurse-Midwife is educated may reflect stricter criteria that cul- in the concept of public health, and the minated in an amendment to the Health theory and practice of modern obstetrics. Code requiring a refresher course if the The nurse-midwife is made keenly aware candidate has been out of school for of the patient's emotional, social, and more than two years. physical reactions to all phases of the Figure 1-New CNM permits issued 1960-1968, City of New York Department of Health 15 -_ _ _ 0. 0~~~~~ .0 I ssued* * * I I , * , 1 after May 1: 1960 '61 '62 '63 '64 '65 '66 '67 '68 '69 VOL 61, NO. 1. A.J.P.H. NURSE-MIDWIFERY IN NEW YORK CITY maternity cycle: prenatal, intrapartum, Present Status of Certified Nurse- postpartum, interconceptional, and fam- Midwives in New York City ily-community adjustment.18 The New York City Department of Table 2-Total CNM permits issued after Health recently conducted a survey that May 1, 1960 through 1968 inquired into the activities of Certified Nurse-Midwives. All nurse-midwives 1960 5 holding permits during 1968 and renew- 1961 16 ing for 1969 were asked to estimate the 1962 22 proportion of time each spent in differ- ent activities. Ninety-four per cent of 1963 25 the survey candidates responded. The 1964 31 average time spent in designated activi- 1965 44 ties as reported by the group is shown 1966 50 in Table 3. 1967 53 Figure 3 presents a graphic display of 1968 67 these proportions. It is notable that Certified Nurse- Figure 2-Total permits issued to CNMs in New York City, 1960-1968, City of New York Department of Health 70 60- 50-' LA E CD 40 0 .JO E C3 30 20 10 0 Issued I J I I J II 1 I after May 1: 1960 '61 '62 '63 '64 '65 '66 '67 '68 '69 JANUARY. 1971 67 Table 3 the role performances of 55 Certified Nurse-Midwife respondents suggests that % of time Newnurse-midwivesYork City currentlyare beingpracticingused in thein A. Administrative duties 16.0 capacity for which they are trained. Nearly one-half of their time is spent B. Nurse-Midwifery Service in actual nurse-midwifery practice; pa- Direct management of patient care (A.P.