Obstetrical Nurse Managers vs. Certified Nurse-Midwives

The Problem:

I’ve written on this subject before, but the more I hear from CNMs being overseen and controlled by corporate nurse managers, the more it seems that the already inherent problems with this heinous hierarchical structure are getting worse. Hospital corporate entities continue to place nurse-managers in control of staff Certified Nurse-Midwives. Nurse managers may have a Master’s Degree and long experience in nursing. Still, his/her education, training, and position in no way make them competent to manage the care provided by CNMs, many of whom have obtained a Ph.D. or DNP educational status. It is neither appropriate nor reasonable for an RN manager to be in a position where they can make assessments and judgments on care rendered by Certified Nurse-Midwives. But nurses in positions of power are forcing retirements and making decisions regarding the conduct, hiring, and firing of CNMs. Increasingly prevalent are scenarios where a nurse decides whether a CNM’s care has fallen below the midwifery standards of practice. Registered nurses in power positions often lack knowledge and an accurate understanding of the midwifery scope of practice. Midwifery models of care are rarely, if ever, respected by nurses.

Unfortunately, there has been a centuries-long antagonism between nurses and midwives. Consistently, hospital nurses working with midwives consider themselves equivalent in knowledge and expertise. It is a false comparison. Nursing has minimal understanding of the midwifery model of care. Nurses are trained in a pathology model of care, and the midwifery model focuses on, among other things, wellness and respect for the normal process of labor and birth. The two professions are not, and never will be, equivalent.

While CNM practice may resemble registered nursing in certain situations of care, this similarity may stem from the fact that most CNMs have actually practiced as RNs at one time. However, advancing to Master’s and Doctorate levels of knowledge, CNMs have more advanced obstetrical training, expertise, and education than hospital nurses. In particular, nurses have no place at all to pass judgment on the care provided by midwives. However, they consider it appropriate and within their purview to criticize midwifery care. It is somewhat confounding that nursing may feel entitled to criticize a model of care they know nothing about. Coming from a strictly pathological point of view, nursing has a very low tolerance for midwifery care. Nurses are totally compliant with physician care and labor management. Yet, they are unable to comfortably allow midwives to render their care, which may adhere to a philosophically diverse, but still safe, way of rendering care. For most hospital nurses, anything different is considered radical or inadequate compared to the nursing and physician approach to maternity care. Apparently, safe care requires only one path, and that is a model of practice that aligns with physician care.

Obviously, nursing’s sense of entitlement to stand in judgment of midwifery care is a significant issue. Furthermore, corporate healthcare is on their side. As a result of these antagonistic attitudes toward care, midwives can be made miserable and paranoid in their workplace. This affects how midwives can care for their patients the way they were educated to do, utilizing a midwifery model of care.

An additional barrier to practice for midwives is that nursing education emphasizes compliance with MD/DO orders, encouraging nurses to trust and accept physician orders solely because of the doctor's specialized training. An overwhelming number of nurses, especially those who have been working for a very long time, are resentful of having to accept orders from a CNM.

I am not aware that ACNM has directly addressed these problems to anyone’s satisfaction. Numerous articles on RN/CNM conflicts highlight the problem's existence but offer no particularly effective solutions. The problems persist. Midwifery in corporate settings remains complicated and stressful. Midwifery, it seems, is still very careful when navigating corporate settings that remain suspicious of the safety of midwifery care. Hospital corporate entities still embrace unfounded suspicions that midwifery care invites malpractice litigation, yet they seem to lack motivation to understand the midwifery model of care. Instead, they warily tolerate midwifery care, perpetuating an attitude that they are nothing more than nurses who can catch a baby.

At the very least, the only way that midwives can survive under nursing corporate management is to have a strong midwifery lead, who can advocate and protect the hospital employee midwives, as well as outside midwives who have hospital privileges. For the safety and sanity of midwives in hospital practice and their patients, a corporate-approved director of midwifery is essential. With corporate status, a midwifery advocate can stand between the CNMs/CMs and those hospital employees who feel entitled to criticize, accuse, and stand in judgment of midwifery care.

I have worked in hospitals with a dedicated midwifery manager, and, in my opinion, this approach significantly reduces stress for both hospital staff and independent midwives. However, it must be an individual who will be a strong advocate, standing between midwives and problematic hospital staff, e.g., nurses, doctors, and hospital administrators. In particular, it may reduce the influence of a nursing manager who has been given the power to make competency judgments against midwives on staff. A CNM intermediary with standing to support midwifery is, I believe, essential for CNMs to practice at the highest levels of their education and experience.

Finally, teamwork is critical for the best patient outcomes. But CNMs, Doctors, and Nurses can, predictably, be the farthest away from what would be considered an effective team. Unfortunately, a hospital’s vision of teamwork may only consist of nurses and physicians who will dominate the patient’s care, leaving no room for midwifery. This has been the status quo in healthcare for a long time. Corporate healthcare is reluctant to recognize and support midwifery. It is as unfortunate as it is inappropriate and, in the end, it negatively affects patient safety. A CNM/Midwife team can work, but it presents its own set of problems regarding traditional hierarchies of care. Doctors will never regard midwives as true partners in care, and CNMs do not necessarily expect them to. The expectation is functional teamwork where one member does not disregard the importance of another. The worst team can be RN/CNM, whose success can depend on an OB department manager who fails to support mutually respectful collaboration among team members. If a nurse manager exhibits negative regard for CNMs, so will her nursing staff. Without a midwifery advocate, staff midwives may quickly become persona non grata, creating a miserable environment for them to provide optimal patient care. Hospital Corporate Management is rarely enlightened, and typical hospital risk management departments don’t help.

Again, I support the presence of a corporate midwife. One with enough power to negotiate with other managers. It is a critically essential role, not only for the mental health of hospital staff midwives, but also for patient safety. It levels the playing field for staff midwives. An upper-level midwifery presence could mitigate the negative antics of anti-midwifery staff, relieve staff midwives from wasting energy on defensive postures, and allow the focus to be on the well-being of their patients.

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