The nurse-midwifery program in is described, and an overview of the past decade is presented. The possible contribution of the nurse- to the personnel needs in obstetrics is discussed. Incentives are needed to stimulate use of nurse-.

NURSE-MIDWIFERY IN

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 -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 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 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 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. , Labor and tient education and student supervision Delivery, P.P. inhospital, P.P. account for an additional one-fourth of clinic and Family Planning their efforts; therefore, the proportion clinic 47.0 of time spent effecting specialty func- C. Patient Education (not related to B) tions exceeds 75 per cent. Further, only Mothers' classes, group confer- three respondents assigned the title of ences, and so on 3A nurse-midwife in their professional set- D. Instruction (exclusive of patient tings spend more than 50 per cent of education) their time in administrative functions. Clinical instruction 22.4 In short, trained nurse-midwives are Classroom instruction 6.5 apparently fulfilling nurse-midwifery E. Research 1.6 roles.14-15 F. Other 3.0 Total 99.9 Figure 3-Percentage distribution of CNM functions, June, 1968-May, 1969

Dired Patient Contat [] No Patient Midwives in New York City spent an Contad average of 73 per cent of their time in A. Administrative duties direct contact with patients. These serv- B. Nurse -Midwifery Service ices included obstetrical management, Direct nanagement of patient care C. Patient fducation patient education, and care given while D. Instruction providing clinical instruction or super- 1. Clinical Instruction vised student experience. This propor- 2. Ctassroom Instruction E. Research tion of direct patient contact is a con- Other servative estimate because 9 per cent of F. the respondents chose to list their pro- vision of "nursing care" under the cate- gory "other." Eleven per cent of the sample or six respondents reported that administrative duties required more than 50 per cent of their time. Three out of these six, however, held supervisory nursing posi- tions; and, although they held nurse- midwifery permits, they were not en- gaged in the practice of nurse-midwifery during the last year. Therefore, only three (5% of the sample) of this ad- ministrative subgroup held nurse-mid- wifery titles. A review of the allocation of time in

68 VOL. 61, NO. 1, A.J.P.H. NURSE-MIDWIFERY IN NEW YORK CITY

Continuity of Patient Care limits. As long as the course of labor Certified Nurse-Midwives provide ma- is normal, the nurse-midwife will man- ternity care to the medically uncom- age the labor and perform the delivery. plicated patient. In the ambulatory care The is consulted whenever units, the nurse-midwives work side by there is any deviation from the normal. side with an obstetrician. The obste- Any treatments, infusions, and medica- trician takes one examining room and tions such as sedatives and analgesia the nurse-midwife takes the other. If are prescribed by the nurse-midwife. the need for consultation arises, the phy- The Approved Certified Nurse-Midwife sician is next door. Orders set down in each hospital's Nurse-Midwifery Service Policy Manual, Prenatal Care define the limits within which the nurse- Depending upon the policies of the midwife may prescribe treatment.14'16 service, the nurse-midwife performs the At time of delivery, if indicated, the total physical examination including nurse-midwife performs a pudendal breast examination, abdominal palpa- block or gives local prior to tion, and complete pelvic examination performing an episiotomy. She manages and evaluation; she takes the Papanico- the second and third stages of labor and laou smear. The heart and lung evalua- repairs the episiotomy. She signs the tion is accomplished by a physician. birth certificate. During the clinical evaluation of the What has been the Certified Nurse- patient at each revisit, the nurse-midwife Midwife's total contribution to labor provides information on maternity care, and delivery in New York City? The family planning, and personal health. Summary of Vital Statistics of New She encourages questions from the pa- York City furnished data on deliveries tient, her husband or other members of performed by nurse-midwives.17 The her family. Follow-through counseling Health Code stipulates that Certified- is provided from visit to visit. Nurse-Midwives must sign the birth cer- A Certified Nurse-Midwife in health tificates of newborns whose delivery they department might care for ap- have managed. The total number of proximately seven to eight prenatal re- live-birth certificates signed by the Certi- visit patients and one or two new pre- fied Nurse-Midwife since 1959 is shown natal patients during a 2- to 21/2-hour in Table 4. Between 1958 and 1963, prenatal session. In this survey, the New when the last old-style midwife retired, York City nurse-midwives were asked to estimate the number of prenatal clinic Table 4-Number of live-birth certificates sessions they attended within the past signed by CNMs, 1959-1968 12 months. Seventy-six per cent of the sample (42 respondents) report prenatal 1959' 10 clinic attendance within the past year. 1960 383 These nurse-midwives averaged more 1961 912 than 2 (2.1) prenatal clinic sessions per week. 1962 1,610 1963 1,493 Impact of Certified Nurse-Midwives in 1964 1,861 the Labor and Delivery Room 1965 1,819 The nurse-midwife provides warmth 1966 1,852 and support to the woman in labor, en- 1967 2,278 couraging her to participate in the birth process according to her wishes and 1968 2,225

JANUARY. 1971 69 Figure 4 Number of live-birth certificates signed by CNMs, City of New York Depart- ment of Health, 1959-1968 24U0 I 2200 I i it/ 2000 1800 IL a*,/ tn 1600

._ aL) 1400 -z

0 1200 -o E 1000 800 600

400 p 200 I I 0 I 0 6 I a a I I I -1 L- L- I I n Y e a r: 1959 '60 '61 '62 '63 '64 '65 '66 '67 '68 there were 20 deliveries recorded by the to the 75 per cent of the sample (41 "granny" midwife.4 These are not shown respondents) who found this aspect of on this table. the inquiry germane to their activities. A slight reduction in the total num- In response to a question inquiring into ber of deliveries occurring in New York the ratio of initial newborn screening City for 1965 and 1968 is apparent. examinations performed to the number Table 5 and Figure 5 display the ratio of live-birth certificates signed by Certi- Table 5-Per cent of live-birth ertificae fied Nurse-Midwives to the live births signed by CNMs, 1959-1968 in New York City. Apparently the utili- zation of the Certified Nurse-Midwives 1959 .01 was unaffected by the 1965 and 1968 1960 .23 drop in total deliveries. There is no 1961 .54 drop in the ratio for that corresponding 1962 .98 year. 1963 .89 Newborn Follow-Up 1964 1.12 1965 -1.15 Opportunities for the performance of 1966 1.21 comprehensive nurse-midwifery differ 1967 1.56 from setting to setting. The discussion of newborn follow-up relates primarily 1968 1.57

70 VOL 61. NO. 1. A.J.P.H. NURSE-MIDWIFERY IN NEW YORK CITY

of deliveries managed, almost all re- supportive contact can be provided only spondents, 38 out of 41, report that they infrequently. Only 23 respondents said perform the screening examination of they were able to visit at least half the every baby they deliver. All but four of mothers they delivered at the time of in- this group (37) always assign the offi- fant feeding. cial Apgar Score to the newborns they Is it possible for a Certified Nurse- deliver. All but 11 perform simple re- Midwife to order an extended hospital suscitation of the newborn in the de- stay if an infant does not nurse or bot- livery room on every occasion when that tle feed well? Four nurse-midwives is required. All but 10 evaluate at least stated that this was possible in their half of their delivered newborns once hospital setups. All others said they have again in the nursery. never been able to extend a mother's Follow-up support is usually offered stay in the hospital for "poor infant by the nurse-midwife to the delivered feeding" reasons. mother at times of infant feeding. Mid- wifery emphasizes an early positive Postpartum-In-Hospital Follow-Up mother-newborn relationship and stresses the importance of offering guidance, The same group of respondents (41) emotional support, and reassurance to involved in labor and delivery manage- each mother. However, because of early ment reported that they routinely see postdelivery-day (48-hour) discharges, the mothers they have delivered for in some hospitals this counseling and postpartum follow-up before hospital

Figure 5-Per cent of live-birth certificates signed by CNMs, City of New York Depart- ment of Health, 1959-1968 1.8

1.5 - _ _

-~1.2- 0)~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~P

o0.9

0.6-

a I I I - I I I Y e a r: 1959 '60 '61 '62 '63 '64 '65 '66 '67 '68

JANUARY. 1971 71 1 _ Lfl s..-' *z;;~~~~...... C~~~~~~~~~~~~~~~~C * C~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~AC

C~~~~~~~~~~~~~~~~~~~~~~~~~~~~L

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C~~~~~~~~~~) LIJ EL..~~~~~~~~~~~~~~m4mLin~~~~~~~~~~~~~~~~~-~~~~~~~~~~~~~~~~~~~~~~~c

72 VOL 61. U A.J.P.H.~~~~~~7 3 ; NURSE-MIDWIFERY IN NEW YORK CITY discharge. At these bedside visits, all Incentive Program Described- but 6 respondents always discuss post- Developing a Nurse-Midwifery Service partum clinic care and all but 6 al- ways counsel in family planning. While Eighteen months ago, the New York child is also discussed, fewer City Department of Health instituted Certified Nurse-Midwives (28 out of 41) a nurse-midwifery service through the have the opportunity to include this Maternal and Infant Care (MIC) Proj- area in every postpartum check before ects.18 Its mission was to stimulate the discharge. During the postpartum bed- use of nurse-midwives in patient care, side rounds, the Certified Nurse-Mid- a goal long encouraged by health care wives also check the breasts, fundus, planners.'9-26 lochia, and episiotomy repair. A 25-page guide for the development of a Nurse-Midwifery Service was dis- Four-Week Postpartum and Family tributed to the 12 hospitals where ma- Care ternity care services were affiliated with Planning the MIC Projects. The guide recom- The nurse-midwife performs the four- mended that nurse-midwifery services week postpartum examinations in the be developed in the major hospital- clinics giving priority to those patients clinic affiliation programs as rapidly she has personally delivered. This con- as funds and personnel were available.16 tinuity of care allows an individualized As incentives, (1) The MIC Projects, follow-through of education concepts through the director of Nurse-Midwifery and support. If the postpartum exam- Services, offered to recruit nurse-mid- ination reveals no complications and wives. With the concurrence of the depending upon the desires of the pa- chiefs of obstetrics in each participating tient for contraceptives, the nurse-mid- hospital, MIC would select a Certified wife may provide the mother with con- Nurse-Midwife for employment by the traceptive pills or insert an intrauterine hospital. device in accordance with the Ap- (2) Employment arrangements were proved Certified Nurse-Midwife Orders. made with the understanding that the In Health Department Postpartum nurse-midwife would devote approxi- Family Planning Clinics, the Certified mately 50 per cent of her time to proj- Nurse-Midwife will care for 9 to 11 pa- ect clinic patients in the community and tients during a 2- to 21/2-hour clinic 50 per cent of her time would be de- session. For the 12 months covered in voted to patient care in the hospital. The the survey of Certified Nurse-Midwifery project would reimburse the hospital for functions in New York City, 82 per cent half of the nurse-midwife's salary. of the sample of nurse-midwives (45 re- (3) Guidelines for establishing a spondents) reported that they attended nurse-midwifery service included job 756 postpartum, 975 family planning, descriptions for the Certified Nurse- and 2,070 combined postpartum-family Midwives, a patient care program chart planning sessions. Projecting that the and an organization chart describing average Certified Nurse-Midwife sees a the dual responsibilities of the nurse- minimum of 10 patients per session, ap- midwife within the community-based proximately 38,000 of New York City's Maternal and Infant Care Clinic and postpartum or family planning patient the hospital inpatient services. visits were provided by Certified Nurse- Figure 6 shows the Organization Midwives between June, 1968, and May, Chart."6 Notice the dual involvement of 1969. the Certified Nurse-Midwife in both

JANUARY, 1971 73 the hospital's inpatient units and the City in the person of the nurse-midwife. Health Department MIC community- The professional role was well defined; based clinics. As may be seen, medical further, it had been endorsed by the De- supervision is provided at all times; and partment of Health. It would seem that coordination of nurse-midwifery services all of the conditions for utilization of is accomplished by the director of the this health role existed. However, it is Nurse-Midwifery Services, through the one thing to establish a training pro- Central Office of the MIC Projects. gram for a new health worker, and even to clear away the legal underbrush The Patient Care Program Chart16'27 with licensure, but it is quite another for The health professionals involved in that new health worker to take hold and attending the medically uncomplicated contribute significantly to health care. maternity patients are shown in Figure This program in nurse-midwifery demon- 7. It is apparent that the team approach strates that incentives are needed to is used. stimulate use. (4) Additional incentives were pro- 2. We have presented an overview of vided in that the director of the Nurse- nurse-midwifery in New York City dur- Midwifery Service Program recruited ing the last decade, a period charac- the Certified Nurse-Midwives, screened terized by a stable birth rate for the them for eligibility for a New York first five years and, notably, a declin- City permit to practice Nurse-Midwifery ing birth rate in the three subsequent and, further, recommended the appro- years. Statistics tabulated for New York priate salary for each Certified Nurse- City thus far in 1969 show a rising Midwife. Salaries are quoted according birth rate and a 3 to 4 per cent in- to the nurse-midwives' educational crease in the number of births. The level preparation and experience. of present efforts in fertility control may not be sufficient to reverse this trend Results of the Incentive Program substantially, since the phenomenon may The response of the affiliating hos- derive from the arrival at reproductive pitals to the Nurse-Midwifery Service age of that portion of the population Program has exceeded expectation. Since referred to as the postwar "baby boom." the inception of this program 18 months Therefore, given the growth of nurse- ago, 10 nurse-midwifery service affilia- midwifery in an era that was not char- tion programs have been established. acterized by extraordinary pressures, Two services were established where in one can only predict its growing im- the past only a Nurse-Midwifery Edu- portance as the postwar population bulge cation Program functioned. Five totally itself creates a new wave of births. new Nurse-Midwifery Service Programs 3. The nurse-midwife as a member of were initiated in hospitals that never the obstetrical team, as this survey docu- before had employed nurse-midwives in mented, provides patient care in every any capacity. Three additional hospitals aspect of the maternity cycle, including have requested Certified Nurse-Midwives family planning. We have seen her con- for service. Nurse-midwives were re- tributions to patient care and her latent cruited for these additional nurse-mid- but steady growth; we have demon- wifery services; initiation took place in strated that incentives will stimulate the the fall of 1970. Figure 8 displays the use of nurse-midwives. The incentives in growth in Nurse-Midwifery Services. New York were from federal grants for Maternal and Infant Care-Family Plan- Concluding Observations ning Projects. 1. A potential solution to manpower Additional incentives could be de- needs in obstetrics existed in New York veloped through public and voluntary

74 VOL. 61. NO. 1, A.J.P.H. NURSE-MIDWIFERY IN NEW YORK CITY

Figure 7

NURSE-MIDWIFERY SERVICE

PATIENT CARE PROGRAM The Medically Uncomplicated Patient I Maternity Hospital :cycle L Hospita I Community Iw 1 I- In-Patient Service I I Satellite Clinic

L.P.N. P.H.N. C.N.M. M.D. Month M.D. C.N.M. Obs.N. -_ x P.H.N. Conference II _Complete-_4Physical Ex.I 4 0) 1' *** frenatal Cl. I *z [Prenatal Cl IP.R.N. Home IPrenatal Cl Visit +______0 Visit1==-=-Prenatal C1 P.H.N. 'P.R.N. Prenatal Cl 01 Conference Home Visit _ - 0 0 1 Prenatal-r ,a_,I Ll1LI 4* f a C1 4 lenata _6 _ Labor I I Delivery b P.R.N. pPost Partum - 4- Visit _---- b P.H.N. Egmoe DischargedI Conference Post Partu,xam. A4Iwks Fami ly ,'1 I Plannin 9 ]...£rst Cycle Exam 2 Planning 3 4 5 6 Semi-Annua Physical Ex 7 _~-. 4 . -Pill +I.U.DT. Fami ly P.R. N. Home Planning 8 Key: 4-- Visit 9 M.D. = Attending Obstetrician 10 or Obs. Resident 11 = Certified Nurse-Midwife P.H.N. Annual 12 C.N.M. Complete- Physical Ex wConference 13 P.H.N. = Public Health Nurse PilluI.U.D.- Family P. R.N. Home PlanningI 4--- 14 Nurse Viisit-Visit IIMiedAppointmentM Appointment Obs.N. = Obstetrical 15 L.P.N. = 16 4- = Providing Pt. Care 17 4 onth -- = Home Visit = P.R.N.

m Nuning0hoin e4 Nitilk -Iwrrirt#-%'tJ. -1. No. 3. SFI'rl'FNINFR. IINIti

JANUARY. 1971 75 Figure 8-Certified Nurse-Midwives performing deliveries in hospitals, by type of program and by years in New York City

M. I.C. affiliated and partially financed N -M service ZE.~j:: Hospital initiated N - M service PENDING _ts ~ Nurse - Midwifery educational program - - - - ~~~~~~~~~~~~JACOBI

ST. MARY'S

FOR DHAM

LINCOLN

BROOKLYN JEWISH

DOWNSTATE

- - - t - - BROOKDALE

I 'TT.. HARLEM

METROPOLITAN -FLOWER

_* - L ROOSEVELT

KINGS COUNTY

COLUMBIA -PRESBYTERIAAN P rogram initiated: U I I I I I I I I I I Years 1955 '56 '57 '58 '59 '60 '61, '62| '63= '64r::::.:'65 '66 '67 ~~~~~~CUMBERLAND'68 '69 '70 First C.N.M. M. I.C incentive permits issued program begins health insurance plans that offer hos- ACKNOWLEDGMENTS - Sincere thanks are pitals proportionate payment for the accorded to Mr. Nick Nicholas, director, Sta- tistical Services, MIC-FP, Department of specialty services rendered by the Certi- Health, for statistical guidance; to Mrs. Lucille fied Nurse-Midwife. For example: group Goodlet, research associate, MIC-FP, Depart- practice medical care programs-such ment of Health, for assistance in data interpre- as the Kaiser Plan on the West Coast tation and role conceptionalization; and Mr. and Health Insurance Plan (HIP) on Robert Zarafa, medical illustrator, for the the East Coast-would improve the graphic portrayal of the data. quality of maternity care by the em- REFERENCES ployment of nurse-midwives. At the same time this would help solve the 1. Harris, David. The Development of Nurse- Midwifery in New York City. Bull. Am. problem of the increasing shortage of College of Nurse-Midwives Vol. 14, No. 1, medical manpower. 1969.

76 VOL. 61. NO. 1. A.J.P.H. NURSE-MIDWIFERY IN NEW YORK CITY

2. American College of Nurse-Midwives. Edu- 15. Thomas, Margaret W. The Practice of cation for Nurse-Midwifery. (50 East 92nd Nurse-Midwifery in the United States. St.), New York, N. Y., 1958, p. 12. Washington, D. C.: Department of Health, 3. New York City Health Code: Nurse-Mid- Education, and Welfare, 1965. wifery (article 43). City of New York 16. Lang, Dorothea M. Nurse-Midwifery Serv- Department of Health, 1966. ice Program of the Maternal and Infant 4. Weisl, Bernard A. G. The Nurse-Midwife Care Projects and Participating Hospitals. and the New York City Health Code. West. City of New York Department of Health, J. Surg. 71:266 (Nov.-Dec.), 1963. 1968 (unpublished). 5. Fox, Claire Gilbride. Toward a Sound 17. Summary of Vital Statistics-The City of Historical Basis for Nurse-Midwifery. Bull. New York. City of New York Department Am. College of Nurse-Midwives XIV,3:81 of Health (125 Worth Street, New York, (Aug.), 1969. N. Y. 10013), 1959-1968. 6. American College of Nurse-Midwives. 18. U. S. Department of Health, Education, What Is a Nurse-Midwife? (50 East 92nd and Welfare Grants for Maternity and St.), New York, N. Y., 1969. Infant Care Projects, Washington, D. C. 7. Crowell, F. Elizabeth. The Midwives of 1964. New York. A report submitted at a special 19. Daily, Edwin F. Maternity Care in the meeting of the Public Health Committee, United States-Planning for the Future. Association of Neighborhood Workers, Am. J. Obst. & Gynec. 49:128-143 (Jan.), New York Academy of Medicine (Dec. 1945. 20), 1966. 20. . A Vision of Service to 8. Van Blarcom, Carolyn C. Visiting Ob- Mothers and Babies. Bull. Dept. of Health stetrical Nursing. Trans. Second Annual (Commonwealth of Kentucky) 15,6:10 Meeting, American Association for the (Jan.), 1943. Study and Prevention of Infant Mortality, 21. Hellman, L. M. Nurse-Midwifery in the Chicago (Nov. 16-18), 1911. United States. Obst. & Gynec. 30:883-888 9. Taussig, Fred J. "The Nurse-Midwife." (Dec.), 1967. Quoted by Sister Theophane Shoemaker 22. American Medical Association. Proc. AMA in: History of Nurse-Midwifery in the National Conference on Infant Mortality, United States. Washington, D. C.: Catho- August 12-13, 1966. (535 N. Dearborn St.) lic University of America Press, 1947, Chicago, Ill., pp. 15, 16, 25, 64, 67, 114. pp. 8, 9. 23. Crawford, Mary I. Potential of the Urban 10. Crawford, Mary I. Nurse-Midwifery at Nurse-Midwife. Am. J. Nursing 63:192 Columbia. Bull. Am. College of Nurse- (Sept.), 1963. Midwifery 4,2:56, 1956. 24. Daily, Edwin F. Medical Help from Non- 11. Nurse-Midwifery Permit Section. Myron . Presentation at the 11th J. Stahl, director, Bureau of Permits, and Annual Meeting of the American Society Jean Pakter, M.D., director, Bureau of of Internal Medicine, San Francisco, Calif. Matemity Services and Family Planning, (Apr. 9), 1967. City of New York Department of Health 25. Lang, Dorothea M. Nurse-Midwifery Man- (125 Worth Street, New York, N. Y. power in New York City. City of New 10013). York Department of Health, 1966 (unpub- 12. Research Committee - A.C.N.M. Nurse- lished). Midwifery Statistics. Bull. Am. College 26. Optimum Health Care for Mothers and of Nurse-Midwives XIV,3:70-75 (Aug.), Children. Washington, D. C.: U. S. De- 1969. partment of Health, Education, and Wel- 13. Educational Issue. Bull. Am. College of fare, 1967. Nurse-Midwifery Vol. 10, No. 2, 1965. 27. Lang, Dorothea M. Providing Maternity 14. American College of Nurse-Midwives. Care Through a Nurse-Midwifery Service Functions, Standards and Qualifications. Program. Nursing Clinics of North (50 East 92nd St.) New York, N. Y., 1966. America 4,3:509-520 (Sept.), 1969. Dr. Harris is Deputy Commissioner, Department of Health (125 Worth Street), New York, N. Y. 10013. Dr. Daily is Director, Maternity and Infant Care-Family Planning Projects, and Miss Lang is Director, Nurse-Midwifery Service Program, Maternity and Infant Care-Family Planning Projects, De- partment of Health (40 Worth Street), New York, N. Y. 10013. This paper was presented before a Joint Session of the Maternal and Child Health, Food and Nutrition, Mental Health, , and School Health Sections of the American Public Health Association, at the Ninety- Seventh Annual Meeting in Philadelphia, Pa., November 10, 1969.

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