title: The practice of nurse-midwifery in the era of managed care: reports from the field.
abstract: OBJECTIVE
  The purpose of this paper is to describe the reports of certified nurse-midwives (CNMs) about how changes in the financing and organization of health care in the late 1990s influenced their ability to serve vulnerable populations and provide a woman-centered, prevention-oriented midwifery model of care.
  
  
  METHODS
  A 13-page survey was mailed to all CNMs ever certified by the American College of Nurse-Midwives (N = 6365) in July 1998. The survey included closed- and open-ended questions. A total of 2405 CNMs responded: of these, 2089 were in clinical practice during the study period (1997-98) and 82% of the 2089 (N = 1704) wrote responses to the open-ended questions and were included in the qualitative database. We present responses to the closed-ended questions about seven domains of practice and elaborate on three major themes identified through content analysis of the qualitative data.
  
  
  RESULTS
  The majority (57%) reported that the changes in the larger health care environment had influenced their practices during 1997-98. The effects most frequently reported were 1) increased client loads (31%); 2) altered style of practice (30%): 3) inability to serve the same populations; (20%); 4) decreased client loads (20%); and 5) increased administrative duties (17%). Three major themes were identified and elaborated upon in the qualitative data: 1) challenges to the style of midwifery practice related to the managed care environment; 2) the loss of socially and economically at-risk women from CNMs' client base; and 3) barriers to high quality and comprehensive services for women.
  
  
  CONCLUSIONS
  During the late 1990s as managed care was expanding and health systems were merging, a significant number of CNMs in the field described threats to their ability to sustain economically viable practices and a style of care consistent with the woman-centered, prevention-oriented midwifery model.
authors.affiliation: Department of Maternal and Child Health, Boston University School of Public Health, Massachusetts 02118, USA. loism@bu.edu
authors.forename: Lois
authors.initials: L
authors.lastname: McCloskey
authors.forename: Holly P
authors.initials: HP
authors.lastname: Kennedy
authors.forename: Eugene R
authors.initials: ER
authors.lastname: Declercq
authors.forename: Deanne R
authors.initials: DR
authors.lastname: Williams
mesh_terms: D001291:Attitude of Health Personnel; D003191:Comprehensive Health Care / Q000458:organization & administration / Q000592:standards; D005260:Female; D019538:Health Care Surveys; D006297:Health Services Accessibility; D006801:Humans; D008329:Managed Care Programs / Q000458:organization & administration*; D008427:Maternal Health Services / Q000458:organization & administration* / Q000592:standards; D009721:Nurse Midwives / Q000523:psychology* / Q000706:statistics & numerical data; D018802:Patient-Centered Care; D011247:Pregnancy; D011364:Professional Practice / Q000639:trends; D011787:Quality of Health Care; D011795:Surveys and Questionnaires; D014481:United States; D035862:Vulnerable Populations; D016526:Workload