Public Release: 

The United States Should Adopt Nurse-Midewifery As Standard Of Care For Normal Deliveries

Public Health Reports

"Obstetrical care in the United States is burdened by high costs and a paradoxical inability to bring rates of infant mortality in line with those of other developed countries." Public Citizen's Health Group looked at the costs and outcomes of obstetrical care and found that a greater reliance on the use of certified nurse-midwives (CNMs) could help solve these problems. Over the last 20 years, the number of births attended by nurse-midwives has increased tenfold, to 5% of all hospital births, yet this is insignificant compared to the 75% average across Europe.

"Our findings suggest that the training of CNMs and their orientation toward childbirth as a normal event makes them particularly well suited to play an increasingly important role in remedying two difficult problems in U.S. obstetric care--the excessive use of costly and often unnecessary medical interventions during births to normal, low-risk women in U.S. hospitals and our country's slow progress in improving the health status of newborns."

Public Citizen recommends that:

  • State laws and regulations governing the practice of nurse-midwifery should be reviewed to determine their impact on the provision of CNM services and revised to better encourage CNM care.

  • More opportunities should be made available for the education of CNMs.

  • Sustained public information campaigns on the quality, cost-effectiveness, and client satisfaction ratings of nurse-midwifery care should be implemented.

The authors made their recommendations based on the following rationale:

Cost. Public Citizen found that in 1992 nearly one-quarter of pregnant women in hospitals had cesarean sections. In 1994, 60% of all pregnancies resulting in live births used ultrasonography, despite the fact that the American College of Obstetricians and Gynecologists says that its routine use "cannot be supported form a cost-benefit standpoint." Electronic fetal monitoring is also not recommended for routine use, yet 80% of all live births in 1994 involved some electronic monitoring. Nurse-midwives--in juxtaposition with the more action-oriented physicians--have a noninterventionist philosophy of care.

Outcomes. In 1994, 21 other developed nations had lower infant mortality rates than the United States, despite our heavy use of technology. One major difference between the U.S. and the countries that outrank us is that these countries all have some form of a national health program. Another is that midwives provide much of the prenatal and labor and delivery care in all of these countries except Canada. Low birth weight is the driving force behind a large share of the infant mortality rate. Researchers have identified a number of risk factors for low birth weight. Although not all of these risk factors are susceptible to intervention, those that do are likely to be mitigated by the careful screening and constant encouragement of a nurse-midwife who is more likely to spend considerable time with the pregnant women, educating her on good health habits, counseling her on nutrition, and offering a wider range of delivery options.

A report by the U.S. Congress's Office of Technology Assessment concluded that: "The weight of the evidence indicates that, within their areas of competence,.. CNMs provide care whose quality is equivalent to that of care provided by physicians."

Restricted Practices. Lack of awareness among consumers is part of the reason many women have not chosen the services of nurse-midwives, but barriers to access also exist. While nurse-midwifery is permitted throughout the United States, 64% of the CNM practices survey by Public Citizen reported that their practices were restricted in some way. State laws were the source of three notable restrictions: limitation on prescribing privileges, limitations on hospital admitting privileges, and lack of mandatory third-party reimbursements.

Nurse-Midwifery in Florida. Florida is aggressively promoting the use of CNMs as a cost-effective answer to a shortage of maternal health care providers.


CONTACT: Sidney M. Wolfe, MD, Director of Public Citizen's Health Research Group; tel. 202-588-1000; e-mail

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