In the late 1960s and early 1970s, everything changed. Suddenly nurse-midwifery was not only acceptable but inundated with requests for practi- tioners and berated for the lack of nurse-midwives
to meet the demand. The late 1960s and early 1970s were a time of rapid development in nurse- midwifery, with widespread proliferation of nurse- midwifery services and educational programs that continued through the decade.
By the end of the 1970s, nurse-midwifery edu- cation had proliferated to a total of 22 basic educa- tional programs, thereby doubling in 10 years the number of programs developed during the preced- ing 37 years. Fifteen new programs opened during this period of time, of which six subsequently closed (the second date is the closing date):
1972 University of Illinois at Chicago Nurse- Midwifery Program
1971–1975 Loma Linda University Nurse- Midwifery Program, California
1973 University of Minnesota Nurse-Midwifery Program
1973 Medical University of South Carolina Nurse- Midwifery Program
1973 Georgetown University Nurse-Midwifery Program, Washington, D.C.
1973–1984 St. Louis University Graduate Program in Nurse-Midwifery, Missouri
1973–1985 Meharry Medical College Nurse- Midwifery Program, Nashville, Tennessee 1973–1998 University of Kentucky Nurse-
Midwifery Program
1975 University of Medicine and Dentistry of New Jersey Nurse-Midwifery Program
1975 University of California, San Diego Nurse- Midwifery Program
1974–1997 U.S. Air Force Nurse-Midwifery Program, Andrews Air Force Base, Maryland 1976 Emory University Nurse-Midwifery
Program, Atlanta, Georgia
1977–1985 University of Arizona Nurse- Midwifery Program
1978 University of Miami Nurse-Midwifery Program, Florida
1978 San Francisco General Hospital/University of California San Francisco Interdepartmental Nurse-Midwifery Education Program
The proliferation of educational programs overex- tended the existing resources for clinical experience for students. A workshop of nurse-midwifery edu- cation and service directors focusing on their inter- dependence was held in 1973. The group divided into task forces to make recommendations for solu- tions to the serious lack of clinical experience avail- able to students. These recommendations were forwarded from the workshop to the ACNM Board
of Directors [26]. Nurse-midwives cooperated with one another in the provision of clinical facilities and clinical faculty for educational purposes. This effort has meant sacrifice on the part of many for the preservation of the profession; the joy and motiva- tion of the practicing nurse-midwife comes from providing services directly to women, their babies, and their families.
A number of factors contributed to this un- precedented growth in nurse-midwifery education and practice sites:
1.Official recognition by organized obstetrics. A joint statement in 1971 by the American College of Obstetricians and Gynecologists, the Nurses Association of the American College of Obstetricians and Gynecologists, and the American College of Nurse-Midwives recog- nized and supported the development and uti- lization of nurse-midwives [27].
2.Increased visibility and involvement of the women’s movement and feminism, which in- creased feelings of self-worth and self-confi- dence in all women. These attributes led to a natural alliance between women who wanted to participate in and be responsible for their childbearing experience and nurse-midwives, who facilitate the natural and normal processes, provide family-centered care, and promote parental self-determination.
3.Recognition by the consumer. An increasing number of articles about the “new midwife”
were published in major magazines such as Redbook, Newsweek, Life, and McCall’s, in Sunday newsmagazines, and in newspapers such as the New York Times and the Wall Street Journal. Greater consumer awareness and the satisfaction of those experiencing nurse-midwifery care and writing about it led to consumer demand for nurse-midwifery services.
4.Use of nurse-midwives in federally funded proj- ects such as Maternal-Infant Care (MIC), Family Planning monies (314E), Agency for International Development (AID), and demon- stration projects geared toward improving ma- ternal-infant health care and providing family planning services. Through these projects, more professionals became familiar with nurse-mid- wifery. This familiarity dispelled misconcep- tions, and many physicians and nurses subsequently became ardent supporters of nurse-midwifery.
5.The children of the post–World War II baby boom were having babies during the mid-1960s and 1970s. This population peak meant that there was not, and would not be, a sufficient
supply of obstetricians to care for all of the childbearing women in the country. This short- age of obstetricians, combined with the small number of general practitioners doing obstet- rics, highlighted the lack of human resources during this period of time. This shortage led to scrutiny of how best to use the optimal capabil- ities of each health care worker and promoted commitment to the obstetric team concept, which included utilization of the nurse-midwife.
6.Demonstration of the efficacy of the obstetric team concept. The effectiveness of nurse- midwives had been statistically proved repeat- edly since the first studies at the Frontier Nursing Service [28], in the Madera County Demonstration Program in California in the 1960s [29], in every service where nurse-mid- wives had worked, and in the team concept, which decreased by half the infant mortality in Holmes County, Mississippi, in the early 1970s [30].
7.The involvement of nurse-midwives in inter- conceptional health care (i.e., family planning, human sexuality, and gynecological screening) and in neonatal care including promotion of parenting. This involvement fully rounded out nurse-midwifery management throughout the childbearing cycle, thereby providing continu- ity of care to the developing family.
The credentialing mechanisms of individual na- tional certification as a Certified Nurse-Midwife and the accreditation of nurse-midwifery education programs were well established by the early 1970s.
A decade later, both ACNM credentialing mecha- nisms were recognized by umbrella organizations with that purpose: certification was recognized by the National Commission of Health Certifying Agencies, and accreditation of basic nurse-mid- wifery education programs was recognized by the U.S. Department of Education.
The first private practice with nurse-midwives began in the early 1970s [31]. With the consumer
“discovery” of the nurse-midwife came a burgeon- ing of private practice nurse-midwives, and another inhibiting misconception was laid to rest:
• Misconception: Nurse-midwifery is second- class care for second-class citizens. It follows that nurse-midwives can be utilized only for care of the indigent and will never be accepted by middle- and upper-class patients.
• Fact: By the mid-1970s, nurse-midwives were in practice with physicians all over the country, taking care of middle- and upper-class patients.
According to a 1976–1977 survey by the American College of Nurse-Midwives [32], ap-
proximately 26 percent of all nurse-midwives practicing nurse-midwifery worked in some form of private practice arrangement. Nurse- midwives are well accepted by these women, who often prefer to be seen in the office and to be delivered by the nurse-midwife as long as their condition does not require the physician member of the team. This preference is largely a result of the time the nurse-midwife spends explaining and teaching during the office visits, the commitment of the nurse-midwife to the woman throughout labor, and the practical ap- plication of the beliefs of the nurse-midwife in promoting a family-centered, normal childbear- ing experience. This preference places the ob- stetrician in the difficult position of feeling displaced at the same time that the obstetrician is initially introducing the nurse-midwife into his or her private practice and is creating the environment in which women will come to ac- cept the nurse-midwife by virtue of the care the nurse-midwife gives them. Mutual professional understanding and patience are required in order for the woman to obtain the maximum benefit and advantages of the physician/nurse- midwife team approach.
The misconception arose from the fact that nurse-midwifery practice for years took place mainly in large medical centers and city hospitals serving the medically indigent or in remote rural areas with few physicians. This initial concentration of nurse-midwives in settings serving women from lower socioeconomic groups occurred because the nurse-midwife’s professional services were wel- comed first in areas where help was most desper- ately needed.
During the 1970s, nurse-midwifery had be- come not only acceptable but also desirable and de- manded. After years of struggling for existence, nurse-midwives now faced the problem of a severe shortage of supply to meet the demand. The first edition of this book (1980) discussed the conflicting pressure on nurse-midwives in the 1970s:
On the one hand is the need for providing quantity services sufficient to warrant the expense of utiliz- ing nurse-midwives by the established health care system and the need for nurse-midwives to be able to function within this system to benefit mothers and babies either desiring or needing care in the system. On the other hand, there is a small but growing number of consumers who are dissatisfied with the health care provided by the system, who desire care outside of the system, and who look to nurse-midwives for support and services. Lack of
response with childbirth alternatives (e.g., hospital birthing rooms, childbirth centers, or carefully se- lected home births) further disenchants the con- sumer with professional health care and fosters the development of often untrained lay midwives or birth attendants, and a do-it-yourself movement.
Affecting this conflict is the issue of nurse-mid- wives being able to collect third party payment for services. The resolution of this conflict has far- reaching implications and ramifications and consti- tutes the challenge nurse-midwifery has had in the latter half of the 1970s. [33]
Lay midwifery developed in the 1970s in re- sponse to the disenchanted childbirth consumers who wanted to give birth to their babies outside of the hospital. The term lay midwiferyin the 1970s and 1980s referred to all non–nurse-midwives, whose preparation in midwifery was highly vari- able. Today the term refers to noncredentialed mid- wives. Some lay midwives prefer to call themselves traditional, community, empirical, or independent midwives. Sometimes the term direct entry is mis- used to mean lay or noncredentialed apprentice- ship-prepared midwives. The term direct-entry midwives originated many years ago in England, where non-nurses completed a formal educational program leading to the same credentialed and regu- lated professional midwifery as nurse-midwives.
Lay midwifery struggled with its early identity, as lay midwives disagreed sharply among themselves regarding the desirability of formal education, stan- dards, credentialing, and regulation.
A number of groups and organizations sup- portive of lay midwifery and home birth sprang up during the 1970s: NAPSAC (National Association of Parents and Professionals for Safe Alternatives in Childbirth), HOME (Home Oriented Maternity Experience), ACHI (Association of Childbirth at Home International), and NMA (National Midwives Association). Existing organizations such as ICEA (International Childbirth Education Association) and La Leche League added their sup- port. The first national meeting of lay midwives took place in 1977 in El Paso.