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Comparison of rural and urban certified nurse-midwives in Arizona
COMPARISON OF RURAL AND URBAN CERTIFIED NURSE-MIDWIVES IN ARIZONA
llene Gordon, RN, D~PH, and Julie Reed Erickson,
RN, pm
AWl’R4CT A surveyof certifiednursemidtiver (CNMsl in Arizona was carded out in 1590 to fxovfdedata for maternitysewice planningin the state.lnfwmatfon was gatheredon locationand scopeof CNM practice,bar&~ to pmdce. and the contributionof CNMs to maternitycare. Demographica”d clinicalpracttcecharactertstks of urban and rural CNMs were aLo compared.Urban and rural CNMs are stgnlRcantfy differentin terms of education(urbanCNMs are muchmore likely to havemaster’sdegrees)and “umber of yearssinceffrstcertfftcatfo”(urban CNMr have bee” certifieds&rdfirawlv longer). Rural midwivesare mcxelikely to be under the age of 40. Health senlcer protided by urbanand ruralCNMs were comparedwith eachotherand tith ~Uonal data. Mtdwiwr in mral areas of Adzona are more likely to provide comprehendvenurse-mtdwifey servicesthan are either urban Ationa midwivesor U.S. midwivesas a whole. Urban andruralCNMsdexrtbed lackof physicianbackupasamajorbardertonurse-midwifery practicein rural areas.lack of hospitalprivilege was anothermajor obstaclenoted by rural nurse-midtives.Adzo”a CNMs felt they could protide comprehensive,cost-effecttvematernity sewices in rural areas that would tmprow accessto care, patient satisfaction. and maternaland child health outcomes.
Health care problems in rural Amerfa are substantialand growing Nearly 57 mtllion people. compdsf”g 23% of the U.S. pop&tfcfl, live in rural areas. In 1990. at the request of Congress, the U.S. Office of Technology Assessmentcompleted a study of health care in r.iral America. This report fndlcates that major health care pmbkms of rural residentsare low income (one in six mrel lam&s lives in povertyl, a lack of health insurance (18% of those under age 65 are uninsured),
and the need to travel long distances to receive health care (1). Rural residentswaft long-a from the onset. of symptoms before seeking medical care, and by the ttme they do seek care, th+y are sicker than their urban counterparts. Rural families are less likely to have health insurance. and thus spend a dlspropatfonate share of per capfta income on health care (2). Rural families have higher rates of infant mortality, accfdent-related mortality, chronic disease, and disability than their urban counterparts. However, mral dwellers have slightly lower overall mortality rate-~ thanurbandwel!ersona”a~&tionallevel. According to the Federal Office of Technologj Aswssment: Rural areasAndit increasinglydifficult to recruitand retainthe varietyof qual-
Journal d Nu,se.Mfdwfkry
.
areasfaces&a shorir&. Nation&,. half a mlffla” rural residentslfw in countieswith rw phystclanhatred to provide obstetrtccare (1,. Although rural residents are at risk for increased morbidity and premature mortality, they are less likely to have accessto health care sewtces than do urban residents. Although the need for health care is hiah. the availabilthr of health practitioners and sentices is IOW. There have been numerous anecdotal reports of factor3 i”tlue”ci”g practitioners’ decisions to locate In “Iml areas. Although several studies have discussed the effects of nrml rokttons on medical studenk and residents (3-71, there are scantdata about location de&ions 05 regtstered nurses
_
Vol. 38. No. 1, January/February 1993 C.XW?,E2W$C&W
and certified nursemidivivee (CNMs). A recent article in the Journal@ Rum1 Health that correlates students’ backgxoundsand expertewes with choices of locales for practice indicates that locale of the student’s educational program may be of primary importance (8). Rural Arironans suffer shortagesof all kinds of health care professionals. For example. although opproximately 21% of the population lives in rural areas. only 13% of the regtstered nurses, 16% of the pharmacists, 10% of the social workers, and 12% of the physicians live in rural areas (91. Th& are currently 37 areas in nual Arizona fedemllv deskmated as health professional &ortagi areas. In Ationa, as in other states, the number of physicians willing to pmvlde matemtty care in rural areas has decreasedduring the past decade (lo15). Simultaneously. there has been an increase tn the rates of women receivinginadequate prenatal care and of infants ban at low and very low birth weight (16). In responseto these trends, the Arizona state legfslature mandated that the University of Artzone College of Medicine develop a ofan for overcomins materniti ser. vice inadequacies in the state. The number of births recorded in Arizona has increased dramatically in
Uene Gordon, RN.o,~“, is e resemzh as&tant pmfexwr and Director of the PhoenixRuml He&h Office in the Departmentof Ferni,,,end Communiry Medicine. SouthwestBorder Ruml Health ResearchCenter, lJniwni@ of Arbona College of Medicine. She wm formerly afacufty member in the CollegeaofNursingat the Universityof EhftkhColumbia and Arbmno State Uniwnity, and tuas a depwiment choir in Community Health Nwsing at A~WonoSt& Uniwrsity.
doumal of Nurse-Midwifery
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recent years, primarily as a res”,, of an increase in the number of women of childbearing age. Between 1980 and 1989. Arizona births increased 34.9% to a total of 67,128 births. Although the numbers of births have increased in all counttes during the past decade, the percentage of births to women residing in rural counties declined gradually from 28.7% to 24.4% of all &hs. As the number of births increased in Ationa, rates of infant mortalit and preterm birth also increased. AC though the infact mortality rate of Arirona is sliqhtlv lower than that of the United States: Arizona’s rate rose to 9.7 wr l.OUO bits in 1988. which was higher than for any previous year since 1981. The proportion of pretenn bhihs (births before 37 weeks of wstation) also increased each yea from 1986 to 1988 in Artzona. In 1987. the last year for which national data are available, the propotion of preterm infants was 12.6% in A~iona. compared with 10.2% for the United States as a whole (17). The prop&ion of preterm births in Arizona grew to 12.8% in 1928 Although infant mortaltty and preterm bhth rates worsened in A&am. fewer women received early prenatal care. According to the Atina Department of Health Sewices. the percentage of women who began prenatal care in the first trimester of pregnancy fell to 66.2% in 1988. the lowest level in a decade. By contmsf intheUnitedStatesasawholetheper. eentageofwomenbe~nningprenatal careintiwArsthimeeterexceeded?6% everyyeerfmm197?xo1987(17).The rate of women receiving inadequate prenetelcarewas higheetinrwalareas of Akona. In 1988, the pxcentageof women with inadequate prenatal care (definedbytheArizoMDepartmentof HealttSeticesasfewerthanfiveprenatal visits)was almost double in rural counties (136.9 per 1,0001ivebkihs), comperedtithurbanMadco~~llnty (78.5 per 1,COOlive births) (16). Although multiple barters prevent
Vol. 38. No. 1. danuary/Februaw 1993
women fmmrecei”ing pen&I care, the decreasing avaiLability of p~wklers of maternity care has been of paramount fmpatance. The toedequate sup& of metemitv caw. wo+idezx in II& -Arizona has-been’weu daw mented (13.17-191. Abhouoh there is na shortage of phystctans in the state, there is a shatage of physictane w+Utng to practke in rural areas Moreover, many physicians who do p”ctke in rural have dfscontinued pmvidtng maternity wvices, perhaps in response to the increasing cat.5 of lIrdpm&e inwuance. Thhiyone colmn”ntties in Artwna have been designated shortage areas for primary care phwctans, and 12 have no physktaw within a 30-mile radius who are willing to provide maternity care (10). A5 the number of physkfans providing matemfty ser vices in rod ti has decreased, a trend has emerged where pre~ant women lack prenatal care and travel to distant hos@als only for deliver)r. CeIlad nurse-mkh”i”es ca” function as alternatives to phystins in pmvidtng maternity care. Numerous studteehave documented the impact and effectiveness of nurse-midwives in increasing accessto care, decreesira costs, and providing a broader range of mater& care &vices (14, 2CQ4). Caitfied nurse-midwives have been particulady effective in improving the health of chtldbeartng women and of infants in rural awes (1. 25, 26). Since the establishment of the Frontier Nursing Setie in Kenh& 65 yeas ago. CNMs have greatly improved maternity &es for people in remote areas of the Unfted States (27, 28). In the United States, the number of CNMs and the percentage of infank they delivered grew dram&tCaEyfrom 1982 to 1987, the last year for which national data are wetlaMe (29). Howewr, sutvey data show a decrease in the propor&on of CNMs in small and midsize communities in recent years (1). Although aggregate trends we documented through SWwys conducted by the American Cd-
29
lege of Nurse-Midwives, little stateswific data are available. Whereas therearealsoanecdotalreportsabout mm1 nurse-midwifery practice, no
Historically. CNMs have been an important source of maternity care in Arizona. retified wrse-midwives attended cpproximately 4% of births in the state in 1997; however, the proportion of CNM-attended births in some rural counties exceed 14% (9). Most rural midwives provide wviw on Indian reservationsin the northem pm-l of Arizona 119). As llart of the process to delineate health service provider options for Ationa, a survey of CNM. was undertaken by one of the authors (I. G.). METHODS A smvey of CNMs in Arizona was undertaken in 1990 to provide data for matemftyselvk%pklnnin9forthestate. The objeaives of the survey were to describe sociodemogmphic characteristics, lccation and scope of raclice. barriers and potential contibuticns of Arizona CNMs to maternity Sara. The surqey insbument was a 25item self-report questionnaire developed by one of the authors (1. G.). Data on demwamuhic character& tics-including age. sex, marital status. number of children. ethnicihr. education, and p!ace of r&den&we collected. Descriptions of services provided, types of practice. working conditions, and reasons for actually or potentially discontinuing clinical practice were obtained by responses to checklists. Open-ended questions were used to elicit information on barriers to practice and contributions of CNMs to care in rural Arizona and to identify circumstances that would encourage return to clinical practice, especially in rural Arizona. Surveys were mailed to all nursemidwives cediffed by the Arizona State Board of Nursing, including state-cer-
topractice.
_.
tified Indian Health Set&e CNMs (n = 94). Approximately five nursemidwives employed by the Indian Health Service who were not certified by the state board of nursing were not included in thii population. Excluding CNMs who are certified by but do not live in Arizona (n = 25) and four who could not be located, them were 65 eligible respondents. A cover letter described the legi.. lative mandate and stated that suwey msponses would be aggregated and analyzed to dew&p policy oplfons far the legislature. Usable questionnaires were returned by 60 of the 65 eligible CNMs (a 928 response rate). Fortytwo respondin CNMs currently in clinical practice, with 76% (n = 32) of these practicing in urban areas. According to the U.S. Census Bureau claaiffcation system, the only urban awasofAdmMareMadcopacrnm$ (where Phwnix is located) and Pima County (which includesTucson). The other 13 counties are rural. Data regarding soeicdemogmphic characteristicsof nurse&~, their scope of practice, and perceived barriers to rural practice an&wed using descripdvestatistics.Redponses of tural and urban CNMs ware cornpared using t-terts or chi-square analyses as appropriate.
RESULTS Cha1acteristic.E ofArizona Cedtd Nurse.Midarhres Forty-hvo CNMs certified by the Arizona Board of Nursin9 were pmctlcing in Arizona in 1990. Tkese CNMs u&e ovew~hekning(ywhite (97%) and female 1100%). and ware dbhuv more likely to be c&&t& manfe;l than not 152% versus 43%). Although urban and rural CNMS were similar in these characteristics,they were s&nificantly different in education and number of yea* since miginal certification. Urban CNMs were more likely to have a master’s degree than those in rural
settings (see Table 1). Using a t-test comparison with a separate variance estimate, urban nurse-midwives had been certified significantly longer IP = .013), with a mean of 8.8 years (SD = 6.21. compared with rural nurse-midwives (mean = 5.4 years. SD = 1.9). Length of lime since wiginaf certification ranged from lessthan one year to 32 years for the urban CNMs and from three to eight wears for the rural CNMs. Rural m&:midwives in Arizona are also likely to lx younger than their urban colleagues (Table 2). Overall, 70% of the rural CNMs were age 40 OTyounga, compared with 43.7% of the urban CNMs.
!&ape ofPractice Seventy percent of the CNMs SIXveyed were currently in clinical practice, and 97.6% of these intended to continue working as nurse-midwives. In rural areas. most of the CNMswere employed by the Indian Health Service, and provided care to Native American women. Regardin scope of practice, services provided by urban and rural cNMswreccmparedweachoiher and with national data (Figure 1). ~klNmlareasofArlEonaworo more likely to provide afl aspects of nurse-midwifery services (family planning. well woman gynec&gy. menatal. labor and birth. omtoamvn
midwives as a group. For Adzona, urban and rural differences were must TABLE 1 Educational Levels of Cortifled Nurse-Midwives Pmctlcing In Urban and Rural A&ma* LCWJti0fI
DPgRe
Orbun Rural (II = 32) In = 10)
Less than master’s 15 147%) 8 (80%) Master’s 17 (53%) 2 (zu%l *x2 = 3.37.P = .K
TABLE 2 Age of CNMs by locations of Pradce LOmfiX
2130 3140
1 13%) 13 i41%)
4150 5160 cver60
13 U5%) 5 i1.556) 0
0
7 170%) O 2 (2011 1 (10%)
TOlal
32 llOO%l
10 (100%)
striking in the areas of newborn care and well woman 4ynecokxy. with Nml CNMs more li!&ly to pmvtde these setices. Of the rural CNMs. 80% provide newborn care compared with 15.6% of CNMs in urban practice. well woman gynecology was provlded by 90% of the rural CNMs and 12% of the urban CNhk Rural and urban CNMs were compared according to the tyfx of practtce in which they worked These patterns were verv similar. with 64.5% ofthe urban dNMs and 60% of the rural CNMs employed by inslttutions or agencies. Only swen CNMs in the state. five in urban and hue in rural locations, were self-employed.
Although 76% of the x.&icing CNMs currently work in urban areas of Arizona, 65% of the urban CNMs have lived in rural areas. Moreover, 55% of the urban midwives indicated that they w&d be willing to work in mral areas. Chi-square analyseswere used to identify factors assaiated wttb willingness to work in rural areas. One such factor was previous experience living in rural areas (Table 3). More CNMs who have previously lived in rural areas. were tilling to consider practicing in rural areas than those who have not (70.7% vers”s 33.3%). There were no correlations behveen age, marital status. or having dependents and willingness to live in wal areas.
Barriers
to Practice
01 the 18 CNMs not currently in dnical practice, the most frequent red50” gtven for not pmctictng midwifery was the work/caU schedule invdved 166.74), followed closely by the cost of malpractice insumn~e (55.6%). Other &asans included lack of phecian backup (33.3%). family (22.2%). low salary (16.7%). another job (11.1%). and lack of hospital p&tleges ill.l%j. in f~sponse to the
0 ,f 1
generated in anwer to the openended question: “What are the barrien to pm&e in mat areas?” For atl60 CNMs surveyed, the mai freauentlv cited baniers were problems &th p~ystctans, includtw physician host& and the lack of Dhwictan backqiLow slay, lack oi h&s@& privileges, and tsolation were mentiwd less frequently. An&&g the barrier reqw”ses separately for urban and rural practiiioneen revealed a different @teem @we 21. Among urban pmctittoners. 62.5% described lack of oh,,siC&I backup as a banter to. &al
pital $M rivaled lack of phyictan backup as the most frequently mentioned barrier, oath cited by 40% of the pra&ionels. of the UTban praciitiners, 34.4% daciibed wMkii-Q cmldln~ as a banier, compared with 20% of those who wrkedinNralar~Althwghnone of the rural practfttoners mentioned economic factors or &&ion as barriers to rural pmcike, they were described as tania by 20.1% and 21.996, respectively, of the urban p&?CtitiolletS.
Postpartum I 2
auestlon ofwhetlw tbeu would con&ezreturning to a &&I midwifery pox&m, 10 (55.6%) indicated that they would, whereas etght (44.4%) lwuldlwt Seventeen of the 18 no”!xr&ctng CNMS live in urban areas of Arizona Of these. 10 are emP!oyed in CNMrelated occupations, desattng thems&es as nurses, nurse-educators, or nurse-pmcfitionerj. Two others have chan&d careers, ad fix are rwt em&wd The one rural CNM who is
Labor/Birlh PlenPal Gynecology Family Plan 0
io
too 40 60 60 Percent of CNMs Providing Service
120
potential
FIGURE 1. Services provided by P&icing certified nurse-mkkvives In = 10, in rural Arizona n = 32 in urban Arimna. n = 1.527 in United States).
Jo,,mal of Nurse-Midwifery
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Vd. 38, No. 1. JanuaryiFebruary
1593
contributtons
The contributions to maternity care by nurse-mtdwtves in nwal Adzona mat frequently cited by the CNMs in
31
our sample (Flgure 3) reflect those described by the literehlre, including improving accessto care and patient outcomes. The CNMs felt they could increase patient satisfaction with maternity care by providing comprehensive and cost-effectiveservtces. Discussion Lack of accessto health servicesis a major problem in mm1 areas of the United States. As physicians decline to provide care in rutal areas, states such as ktiuna iC.4 6; Z!tem&Ves. Although politkians and CNMs would welcome the expansion of nursemidwifery services. obstacles to rural practice remain. Cerfihed nurse-midwives are a scarce resource in Arizona. In order for CNMs to provide maternity ser. vices for large numbers of rural women, it would be necessary to tncrew the number of CNMs in the state. encouraqe CNMs who are not cruit and retain CNMs in rural areas. As ~revtouslv noted (19). the number oi births &nded by &ne-midwives in Artzona is increasing while the number of nurse-midwives is not, resulting in a steadily increasing workload. The number of CNMe can be expected to decline in the upcoming years because the number of new &ifications had decreased since the peak year of 1983 (18). Developing and suppaitng an educational ~roqmm for CNMs is essential. Tl;ere-has not been a nursemidwifety educational program in Arizona since 1985. Without a massive influx of CNMs from out of state, the existing pool of nurse-midwives can be expected to shrtnk. Recruiting nonpracticingCNMs into practice may be possible. Although only 18 nonpractidng CNMs currently reside in Arizona, they repre sent 30% of our sample. Although it is not possible to know how many actually would return to work-much less to work in rural areas-most indicate that thejj would consider re-
32
TABLE 3 Previous Experience of Having Lived in Rural Areas and CNM’s Willingness or Unwillingness to Practfce in Rural Areas*
wining to Li”e
How
in R”m,A,eas
L&d
I” = 41,
Houe Not Lived I” = 12,
Willing Not willing
29 (70.7%) 12 (29.3%)
4 K+3.3%1 8 657%)
TOkl
41 (100%)
12 11OO%l
*x2 = 4.05, P = .04
hlming to clinical practice under certain conditions.Effortsshwld be made to minimize barriers to practice, such as the heavy workfcall schedule involved and the cost of malpractice Insurance, which have been identified as betiers to practice by nonpracticing CNMs. The issue of recruiting and retaining CNMs in rural trees is a complex one. Certified nursemidwives in our stidy who had lived in mral areas were far more likely to express willingness to work in rural areas than those who had not To increase the number of CNMs willing to locate in rurel areas, efforts should be made to recruit students from rural areas and to offer rural educational programs. support servtces are esrennal for CNMs who locate in rural areas. Ru-
limp
ral practitioners may require even greeter clinical skill and judgment then urban practitioners. Although rural CNMs frequently practice in facilities that cannot care for sick mothers or infants, they often lxk accessto specialists for consultation and referral (30). In our sample, rural CNMs provide a broader mnge of services than do urban CNMs. As a group, however, they were younger, had been in prectice a shorter length of time, and were less likely to have master’s degrees. Consideration should be given to expending the avaffabilitv of qraduate educe& and c&in&g education for rural CNMs. Simulteneously, barriers to rural practice must be reduced. Many UTban CNMs who might be willing to
Priv
MD Opposition Melprectic* 0
20 40 60 80 Percent01 CNMs ProvidmgService
FIGURE 2. Percent of practidng cetified nurse-midwivescitingbarriersto rural practicein A&one.
Journal of Nurse-Midwifery .
Vol. 38. No. 1. Jane&February
1993
A&ona health status and vital statfstiw. 1980-1989. phoenix: Author. 1991. 10. Am&an A&&my of Family Phys?c!ans. Family physidaars and & St&w a p&z%ional wty study. ffinsas Ci$ (MO): Aut:lor. 1987.
11. Americanc&+ of obsietlicians and Gynecok+s Shate$as and op lions for impovlng xce% to maternal heah care:the obstebicia”-gqn~*t as advocate,Washington,DC Author, 1988.
FIG’JRE 3. Mostfrequentlycitedcontributions cetified nurse-midwives couldmakem run, Arkona. locate in rural awas view physicians as a major barrier. Ceriified nursemidwives who actually work in rural meas identify both physkians and lack of hospital admitting privileges as barden. Even if physicians welcomed CNMs, however. courage
the same
forces that
physicians
obstehics wwld
from
dis-
practicing
disoxua~.~ them from
providing backup servic& for CNMs. These forces include fear of ltabilitv. the closure of rural hospitals, closure of matzmity pitals.
and &e
units in mral hos-
In addition, physicians who
provide maternity care may be discouraged from providing backup for CNMs because the cost of their malpractice insurance could increase 01 because
their
insurance
companies
would not allow it (19). A system to facilitate physlcian backup
for CNMs.
joint physician/nurse-midwlfey
pm-z-
ttce, and accessto hospital privileges must be implemented before CNMs can realize their full potential ternal and infant
as ma-
health care pravtd-
as in both rural and urban areas of the United States.
REFERENCES 1 U.S. congress.Office of Technoloav AssessmentHealth care in rural A&ca (OTA-H-4%1 Washmgton.DC: U 5. Governmenthinting Oflice. 199D. 2. DeFriese G. RichettsT. priman/ health care in rural areas:ai, agendafor research.Health Sew Res 1989:23:93174. 3. BassRI_. Paulman PM. The rural preceptorship az a factorin the resider,n/ s&&an the Neb,&a expmience.J Fam Pmct 198?&17:71.%19. 4. NorrisTE, Nonis SB. The eifat of a rural preceptorship duringresidencyon pmcticesiteselectionand interestin rural practice.J Fam Pmct 1988:27541-4. 5. StelnwaldB. Stehwald C. The effeet of preceptorshipand mm, bafn%g progmmon physicians’practicekcatin de&ion. Med ‘Cal-e1975;13:219-29. 6. Heald KA. Caaper JK. C&man S. Choke of locationof practiceof med. ical vhool graduates:analysisof tv.vsurveys Santa Monica (CA): Rand Cor~o mtior: R.l47iwEW, 1974. 7. Cooper JK. Heald K, Sam& M, Coleman s. Rural or urban practice:faLto,s influencingthe locatian de&on of primary care physicians. lnquily 1975;12:1%24. 8. Gordon lT. Denton D. The rektionshipafrum,clinicalrotationstowherr RNs ~rach;ce. J RuralHealth lY92;8:2%304. 9. Aao”a Department of Health Services,Office of Flaming and Health Status Monitoring Clasing the decz&:
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12. Gadon R, McMuUenG. WeissB, Nichok AW. The effectof malpmctkeIiability on the deliver9of rural obnphical care.J Rural Health 1987:3:7-13. 13. Gcfda” R, Hit5 B. WaltersJ. Decliningavail&i of phy+zian &&et& sem%ein rural A&cna and medicaf malp~e&sws Pap+rpresentedatthe 117th Annual Meeting of the American PublicHe&hAx&,&,n,Cbii,
1989
Oci 24. 14. H&es
D,
Rosenbarn
S. An
overview of maternal and infant he& wm%cesinmmlAmeria.JRuralHeakb
1989;5:29!!19. 15. Rorenblatt R, Whelan A, Hart f,. Rural obstetrical access in WashiGQtorl sia,e: have we attainedeq”ilibrium?-Seattle:WAMl Rural Health ResearchCenter. 19% 16. ZpsnisKArqwta~pnmatafe~ta~cme. low bIrthweight and infant mortality. Phoenix Altmna oepamnent of Healtb ties. Division of Fzmtly Health Serukes, 1990. 17. Genten J. MI&, C. Artzona health status and vital statisfics 19.53 Phoenix Atina Deparmwt of He& Sezvicw Office of Planning and Health Status t.ionitoliq> 1990 18. Gal!agher K. Gordon 1 Study of the avaifabilityofobstehicaland&erprimay care seties in underserved Arizona Tucson: Rural Health Mfice, De@men* of Fam$ and Community M&?&e, University of A&OM College of Medtcine. 1990. 19. Gordon R. The effecls of malpm&e inswaxce on certified nurse midwives, the case of rural Aiizona J Nurse Midwifery 1990;3599-106. 20. He&b
Reswrcet
and
Setice
Admin&ration. A stxtb reportto the Residedand Congwson the statusof be&h personnel in the United Stata Rockvtlle
33
[MD): Bureau of Health Manpower IDHHS). 1988. 21. Institute of Medkine. Preventing low bihweight. Washington. DC National Academy Press. 1985 22. National Commission to Prevent infant Mortality. Death before life: the tragedy of infant motility. Washington, DC: Author. 1988. 23. Reid M, Morris J. Petinata, care and cart-effectiwnw: changes in health expenditures and bkth outcanes f&wing the establishment of a nurse-mldwlfe prcgmm. Med Care 1979:17:491500.
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24. Rooks J, Weatherby N. Ernst E, Staoleton S. Rosen D. RosenfieldA. Out-
Joumaf of Nurse-“kh&y
practice in a rural setting. J Nurse Midwifew 1988:33:86-92. 27. Poe D. The FNS medical diwc&a-the historical innovation that has assuredthe best in rural health care. Front Nun Sen, Q Bull 1985@:20-4. 28 Vamey H. Nurse-midwifey. Bos@on: Bfackw”XientifrPubIicatioubliea6am 1987. 29. Adams C. Nurse midwifery pmcnce in the United States. 1982 and 1987. Am J Public Health 1989;79:103%9. 30. Bavter L. Nurse-midwifery in a mraf setting: a different pelspectiv’ve. J Nurse Midwifely1989;34309-10.
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Vol. 38, No. 1. JanuayiFebruay
1993
llene Gordon, RN, D~PH, and Julie Reed Erickson,
RN, pm
AWl’R4CT A surveyof certifiednursemidtiver (CNMsl in Arizona was carded out in 1590 to fxovfdedata for maternitysewice planningin the state.lnfwmatfon was gatheredon locationand scopeof CNM practice,bar&~ to pmdce. and the contributionof CNMs to maternitycare. Demographica”d clinicalpracttcecharactertstks of urban and rural CNMs were aLo compared.Urban and rural CNMs are stgnlRcantfy differentin terms of education(urbanCNMs are muchmore likely to havemaster’sdegrees)and “umber of yearssinceffrstcertfftcatfo”(urban CNMr have bee” certifieds&rdfirawlv longer). Rural midwivesare mcxelikely to be under the age of 40. Health senlcer protided by urbanand ruralCNMs were comparedwith eachotherand tith ~Uonal data. Mtdwiwr in mral areas of Adzona are more likely to provide comprehendvenurse-mtdwifey servicesthan are either urban Ationa midwivesor U.S. midwivesas a whole. Urban andruralCNMsdexrtbed lackof physicianbackupasamajorbardertonurse-midwifery practicein rural areas.lack of hospitalprivilege was anothermajor obstaclenoted by rural nurse-midtives.Adzo”a CNMs felt they could protide comprehensive,cost-effecttvematernity sewices in rural areas that would tmprow accessto care, patient satisfaction. and maternaland child health outcomes.
Health care problems in rural Amerfa are substantialand growing Nearly 57 mtllion people. compdsf”g 23% of the U.S. pop&tfcfl, live in rural areas. In 1990. at the request of Congress, the U.S. Office of Technology Assessmentcompleted a study of health care in r.iral America. This report fndlcates that major health care pmbkms of rural residentsare low income (one in six mrel lam&s lives in povertyl, a lack of health insurance (18% of those under age 65 are uninsured),
and the need to travel long distances to receive health care (1). Rural residentswaft long-a from the onset. of symptoms before seeking medical care, and by the ttme they do seek care, th+y are sicker than their urban counterparts. Rural families are less likely to have health insurance. and thus spend a dlspropatfonate share of per capfta income on health care (2). Rural families have higher rates of infant mortality, accfdent-related mortality, chronic disease, and disability than their urban counterparts. However, mral dwellers have slightly lower overall mortality rate-~ thanurbandwel!ersona”a~&tionallevel. According to the Federal Office of Technologj Aswssment: Rural areasAndit increasinglydifficult to recruitand retainthe varietyof qual-
Journal d Nu,se.Mfdwfkry
.
areasfaces&a shorir&. Nation&,. half a mlffla” rural residentslfw in countieswith rw phystclanhatred to provide obstetrtccare (1,. Although rural residents are at risk for increased morbidity and premature mortality, they are less likely to have accessto health care sewtces than do urban residents. Although the need for health care is hiah. the availabilthr of health practitioners and sentices is IOW. There have been numerous anecdotal reports of factor3 i”tlue”ci”g practitioners’ decisions to locate In “Iml areas. Although several studies have discussed the effects of nrml rokttons on medical studenk and residents (3-71, there are scantdata about location de&ions 05 regtstered nurses
_
Vol. 38. No. 1, January/February 1993 C.XW?,E2W$C&W
and certified nursemidivivee (CNMs). A recent article in the Journal@ Rum1 Health that correlates students’ backgxoundsand expertewes with choices of locales for practice indicates that locale of the student’s educational program may be of primary importance (8). Rural Arironans suffer shortagesof all kinds of health care professionals. For example. although opproximately 21% of the population lives in rural areas. only 13% of the regtstered nurses, 16% of the pharmacists, 10% of the social workers, and 12% of the physicians live in rural areas (91. Th& are currently 37 areas in nual Arizona fedemllv deskmated as health professional &ortagi areas. In Ationa, as in other states, the number of physicians willing to pmvlde matemtty care in rural areas has decreasedduring the past decade (lo15). Simultaneously. there has been an increase tn the rates of women receivinginadequate prenatal care and of infants ban at low and very low birth weight (16). In responseto these trends, the Arizona state legfslature mandated that the University of Artzone College of Medicine develop a ofan for overcomins materniti ser. vice inadequacies in the state. The number of births recorded in Arizona has increased dramatically in
Uene Gordon, RN.o,~“, is e resemzh as&tant pmfexwr and Director of the PhoenixRuml He&h Office in the Departmentof Ferni,,,end Communiry Medicine. SouthwestBorder Ruml Health ResearchCenter, lJniwni@ of Arbona College of Medicine. She wm formerly afacufty member in the CollegeaofNursingat the Universityof EhftkhColumbia and Arbmno State Uniwnity, and tuas a depwiment choir in Community Health Nwsing at A~WonoSt& Uniwrsity.
doumal of Nurse-Midwifery
.
recent years, primarily as a res”,, of an increase in the number of women of childbearing age. Between 1980 and 1989. Arizona births increased 34.9% to a total of 67,128 births. Although the numbers of births have increased in all counttes during the past decade, the percentage of births to women residing in rural counties declined gradually from 28.7% to 24.4% of all &hs. As the number of births increased in Ationa, rates of infant mortalit and preterm birth also increased. AC though the infact mortality rate of Arirona is sliqhtlv lower than that of the United States: Arizona’s rate rose to 9.7 wr l.OUO bits in 1988. which was higher than for any previous year since 1981. The proportion of pretenn bhihs (births before 37 weeks of wstation) also increased each yea from 1986 to 1988 in Artzona. In 1987. the last year for which national data are available, the propotion of preterm infants was 12.6% in A~iona. compared with 10.2% for the United States as a whole (17). The prop&ion of preterm births in Arizona grew to 12.8% in 1928 Although infant mortaltty and preterm bhth rates worsened in A&am. fewer women received early prenatal care. According to the Atina Department of Health Sewices. the percentage of women who began prenatal care in the first trimester of pregnancy fell to 66.2% in 1988. the lowest level in a decade. By contmsf intheUnitedStatesasawholetheper. eentageofwomenbe~nningprenatal careintiwArsthimeeterexceeded?6% everyyeerfmm197?xo1987(17).The rate of women receiving inadequate prenetelcarewas higheetinrwalareas of Akona. In 1988, the pxcentageof women with inadequate prenatal care (definedbytheArizoMDepartmentof HealttSeticesasfewerthanfiveprenatal visits)was almost double in rural counties (136.9 per 1,0001ivebkihs), comperedtithurbanMadco~~llnty (78.5 per 1,COOlive births) (16). Although multiple barters prevent
Vol. 38. No. 1. danuary/Februaw 1993
women fmmrecei”ing pen&I care, the decreasing avaiLability of p~wklers of maternity care has been of paramount fmpatance. The toedequate sup& of metemitv caw. wo+idezx in II& -Arizona has-been’weu daw mented (13.17-191. Abhouoh there is na shortage of phystctans in the state, there is a shatage of physictane w+Utng to practke in rural areas Moreover, many physicians who do p”ctke in rural have dfscontinued pmvidtng maternity wvices, perhaps in response to the increasing cat.5 of lIrdpm&e inwuance. Thhiyone colmn”ntties in Artwna have been designated shortage areas for primary care phwctans, and 12 have no physktaw within a 30-mile radius who are willing to provide maternity care (10). A5 the number of physkfans providing matemfty ser vices in rod ti has decreased, a trend has emerged where pre~ant women lack prenatal care and travel to distant hos@als only for deliver)r. CeIlad nurse-mkh”i”es ca” function as alternatives to phystins in pmvidtng maternity care. Numerous studteehave documented the impact and effectiveness of nurse-midwives in increasing accessto care, decreesira costs, and providing a broader range of mater& care &vices (14, 2CQ4). Caitfied nurse-midwives have been particulady effective in improving the health of chtldbeartng women and of infants in rural awes (1. 25, 26). Since the establishment of the Frontier Nursing Setie in Kenh& 65 yeas ago. CNMs have greatly improved maternity &es for people in remote areas of the Unfted States (27, 28). In the United States, the number of CNMs and the percentage of infank they delivered grew dram&tCaEyfrom 1982 to 1987, the last year for which national data are wetlaMe (29). Howewr, sutvey data show a decrease in the propor&on of CNMs in small and midsize communities in recent years (1). Although aggregate trends we documented through SWwys conducted by the American Cd-
29
lege of Nurse-Midwives, little stateswific data are available. Whereas therearealsoanecdotalreportsabout mm1 nurse-midwifery practice, no
Historically. CNMs have been an important source of maternity care in Arizona. retified wrse-midwives attended cpproximately 4% of births in the state in 1997; however, the proportion of CNM-attended births in some rural counties exceed 14% (9). Most rural midwives provide wviw on Indian reservationsin the northem pm-l of Arizona 119). As llart of the process to delineate health service provider options for Ationa, a survey of CNM. was undertaken by one of the authors (I. G.). METHODS A smvey of CNMs in Arizona was undertaken in 1990 to provide data for matemftyselvk%pklnnin9forthestate. The objeaives of the survey were to describe sociodemogmphic characteristics, lccation and scope of raclice. barriers and potential contibuticns of Arizona CNMs to maternity Sara. The surqey insbument was a 25item self-report questionnaire developed by one of the authors (1. G.). Data on demwamuhic character& tics-including age. sex, marital status. number of children. ethnicihr. education, and p!ace of r&den&we collected. Descriptions of services provided, types of practice. working conditions, and reasons for actually or potentially discontinuing clinical practice were obtained by responses to checklists. Open-ended questions were used to elicit information on barriers to practice and contributions of CNMs to care in rural Arizona and to identify circumstances that would encourage return to clinical practice, especially in rural Arizona. Surveys were mailed to all nursemidwives cediffed by the Arizona State Board of Nursing, including state-cer-
topractice.
_.
tified Indian Health Set&e CNMs (n = 94). Approximately five nursemidwives employed by the Indian Health Service who were not certified by the state board of nursing were not included in thii population. Excluding CNMs who are certified by but do not live in Arizona (n = 25) and four who could not be located, them were 65 eligible respondents. A cover letter described the legi.. lative mandate and stated that suwey msponses would be aggregated and analyzed to dew&p policy oplfons far the legislature. Usable questionnaires were returned by 60 of the 65 eligible CNMs (a 928 response rate). Fortytwo respondin CNMs currently in clinical practice, with 76% (n = 32) of these practicing in urban areas. According to the U.S. Census Bureau claaiffcation system, the only urban awasofAdmMareMadcopacrnm$ (where Phwnix is located) and Pima County (which includesTucson). The other 13 counties are rural. Data regarding soeicdemogmphic characteristicsof nurse&~, their scope of practice, and perceived barriers to rural practice an&wed using descripdvestatistics.Redponses of tural and urban CNMs ware cornpared using t-terts or chi-square analyses as appropriate.
RESULTS Cha1acteristic.E ofArizona Cedtd Nurse.Midarhres Forty-hvo CNMs certified by the Arizona Board of Nursin9 were pmctlcing in Arizona in 1990. Tkese CNMs u&e ovew~hekning(ywhite (97%) and female 1100%). and ware dbhuv more likely to be c&&t& manfe;l than not 152% versus 43%). Although urban and rural CNMS were similar in these characteristics,they were s&nificantly different in education and number of yea* since miginal certification. Urban CNMs were more likely to have a master’s degree than those in rural
settings (see Table 1). Using a t-test comparison with a separate variance estimate, urban nurse-midwives had been certified significantly longer IP = .013), with a mean of 8.8 years (SD = 6.21. compared with rural nurse-midwives (mean = 5.4 years. SD = 1.9). Length of lime since wiginaf certification ranged from lessthan one year to 32 years for the urban CNMs and from three to eight wears for the rural CNMs. Rural m&:midwives in Arizona are also likely to lx younger than their urban colleagues (Table 2). Overall, 70% of the rural CNMs were age 40 OTyounga, compared with 43.7% of the urban CNMs.
!&ape ofPractice Seventy percent of the CNMs SIXveyed were currently in clinical practice, and 97.6% of these intended to continue working as nurse-midwives. In rural areas. most of the CNMswere employed by the Indian Health Service, and provided care to Native American women. Regardin scope of practice, services provided by urban and rural cNMswreccmparedweachoiher and with national data (Figure 1). ~klNmlareasofArlEonaworo more likely to provide afl aspects of nurse-midwifery services (family planning. well woman gynec&gy. menatal. labor and birth. omtoamvn
midwives as a group. For Adzona, urban and rural differences were must TABLE 1 Educational Levels of Cortifled Nurse-Midwives Pmctlcing In Urban and Rural A&ma* LCWJti0fI
DPgRe
Orbun Rural (II = 32) In = 10)
Less than master’s 15 147%) 8 (80%) Master’s 17 (53%) 2 (zu%l *x2 = 3.37.P = .K
TABLE 2 Age of CNMs by locations of Pradce LOmfiX
2130 3140
1 13%) 13 i41%)
4150 5160 cver60
13 U5%) 5 i1.556) 0
0
7 170%) O 2 (2011 1 (10%)
TOlal
32 llOO%l
10 (100%)
striking in the areas of newborn care and well woman 4ynecokxy. with Nml CNMs more li!&ly to pmvtde these setices. Of the rural CNMs. 80% provide newborn care compared with 15.6% of CNMs in urban practice. well woman gynecology was provlded by 90% of the rural CNMs and 12% of the urban CNhk Rural and urban CNMs were compared according to the tyfx of practtce in which they worked These patterns were verv similar. with 64.5% ofthe urban dNMs and 60% of the rural CNMs employed by inslttutions or agencies. Only swen CNMs in the state. five in urban and hue in rural locations, were self-employed.
Although 76% of the x.&icing CNMs currently work in urban areas of Arizona, 65% of the urban CNMs have lived in rural areas. Moreover, 55% of the urban midwives indicated that they w&d be willing to work in mral areas. Chi-square analyseswere used to identify factors assaiated wttb willingness to work in rural areas. One such factor was previous experience living in rural areas (Table 3). More CNMs who have previously lived in rural areas. were tilling to consider practicing in rural areas than those who have not (70.7% vers”s 33.3%). There were no correlations behveen age, marital status. or having dependents and willingness to live in wal areas.
Barriers
to Practice
01 the 18 CNMs not currently in dnical practice, the most frequent red50” gtven for not pmctictng midwifery was the work/caU schedule invdved 166.74), followed closely by the cost of malpractice insumn~e (55.6%). Other &asans included lack of phecian backup (33.3%). family (22.2%). low salary (16.7%). another job (11.1%). and lack of hospital p&tleges ill.l%j. in f~sponse to the
0 ,f 1
generated in anwer to the openended question: “What are the barrien to pm&e in mat areas?” For atl60 CNMs surveyed, the mai freauentlv cited baniers were problems &th p~ystctans, includtw physician host& and the lack of Dhwictan backqiLow slay, lack oi h&s@& privileges, and tsolation were mentiwd less frequently. An&&g the barrier reqw”ses separately for urban and rural practiiioneen revealed a different @teem @we 21. Among urban pmctittoners. 62.5% described lack of oh,,siC&I backup as a banter to. &al
pital $M rivaled lack of phyictan backup as the most frequently mentioned barrier, oath cited by 40% of the pra&ionels. of the UTban praciitiners, 34.4% daciibed wMkii-Q cmldln~ as a banier, compared with 20% of those who wrkedinNralar~Althwghnone of the rural practfttoners mentioned economic factors or &&ion as barriers to rural pmcike, they were described as tania by 20.1% and 21.996, respectively, of the urban p&?CtitiolletS.
Postpartum I 2
auestlon ofwhetlw tbeu would con&ezreturning to a &&I midwifery pox&m, 10 (55.6%) indicated that they would, whereas etght (44.4%) lwuldlwt Seventeen of the 18 no”!xr&ctng CNMS live in urban areas of Arizona Of these. 10 are emP!oyed in CNMrelated occupations, desattng thems&es as nurses, nurse-educators, or nurse-pmcfitionerj. Two others have chan&d careers, ad fix are rwt em&wd The one rural CNM who is
Labor/Birlh PlenPal Gynecology Family Plan 0
io
too 40 60 60 Percent of CNMs Providing Service
120
potential
FIGURE 1. Services provided by P&icing certified nurse-mkkvives In = 10, in rural Arizona n = 32 in urban Arimna. n = 1.527 in United States).
Jo,,mal of Nurse-Midwifery
.
Vd. 38, No. 1. JanuaryiFebruary
1593
contributtons
The contributions to maternity care by nurse-mtdwtves in nwal Adzona mat frequently cited by the CNMs in
31
our sample (Flgure 3) reflect those described by the literehlre, including improving accessto care and patient outcomes. The CNMs felt they could increase patient satisfaction with maternity care by providing comprehensive and cost-effectiveservtces. Discussion Lack of accessto health servicesis a major problem in mm1 areas of the United States. As physicians decline to provide care in rutal areas, states such as ktiuna iC.4 6; Z!tem&Ves. Although politkians and CNMs would welcome the expansion of nursemidwifery services. obstacles to rural practice remain. Cerfihed nurse-midwives are a scarce resource in Arizona. In order for CNMs to provide maternity ser. vices for large numbers of rural women, it would be necessary to tncrew the number of CNMs in the state. encouraqe CNMs who are not cruit and retain CNMs in rural areas. As ~revtouslv noted (19). the number oi births &nded by &ne-midwives in Artzona is increasing while the number of nurse-midwives is not, resulting in a steadily increasing workload. The number of CNMe can be expected to decline in the upcoming years because the number of new &ifications had decreased since the peak year of 1983 (18). Developing and suppaitng an educational ~roqmm for CNMs is essential. Tl;ere-has not been a nursemidwifety educational program in Arizona since 1985. Without a massive influx of CNMs from out of state, the existing pool of nurse-midwives can be expected to shrtnk. Recruiting nonpracticingCNMs into practice may be possible. Although only 18 nonpractidng CNMs currently reside in Arizona, they repre sent 30% of our sample. Although it is not possible to know how many actually would return to work-much less to work in rural areas-most indicate that thejj would consider re-
32
TABLE 3 Previous Experience of Having Lived in Rural Areas and CNM’s Willingness or Unwillingness to Practfce in Rural Areas*
wining to Li”e
How
in R”m,A,eas
L&d
I” = 41,
Houe Not Lived I” = 12,
Willing Not willing
29 (70.7%) 12 (29.3%)
4 K+3.3%1 8 657%)
TOkl
41 (100%)
12 11OO%l
*x2 = 4.05, P = .04
hlming to clinical practice under certain conditions.Effortsshwld be made to minimize barriers to practice, such as the heavy workfcall schedule involved and the cost of malpractice Insurance, which have been identified as betiers to practice by nonpracticing CNMs. The issue of recruiting and retaining CNMs in rural trees is a complex one. Certified nursemidwives in our stidy who had lived in mral areas were far more likely to express willingness to work in rural areas than those who had not To increase the number of CNMs willing to locate in rurel areas, efforts should be made to recruit students from rural areas and to offer rural educational programs. support servtces are esrennal for CNMs who locate in rural areas. Ru-
limp
ral practitioners may require even greeter clinical skill and judgment then urban practitioners. Although rural CNMs frequently practice in facilities that cannot care for sick mothers or infants, they often lxk accessto specialists for consultation and referral (30). In our sample, rural CNMs provide a broader mnge of services than do urban CNMs. As a group, however, they were younger, had been in prectice a shorter length of time, and were less likely to have master’s degrees. Consideration should be given to expending the avaffabilitv of qraduate educe& and c&in&g education for rural CNMs. Simulteneously, barriers to rural practice must be reduced. Many UTban CNMs who might be willing to
Priv
MD Opposition Melprectic* 0
20 40 60 80 Percent01 CNMs ProvidmgService
FIGURE 2. Percent of practidng cetified nurse-midwivescitingbarriersto rural practicein A&one.
Journal of Nurse-Midwifery .
Vol. 38. No. 1. Jane&February
1993
A&ona health status and vital statfstiw. 1980-1989. phoenix: Author. 1991. 10. Am&an A&&my of Family Phys?c!ans. Family physidaars and & St&w a p&z%ional wty study. ffinsas Ci$ (MO): Aut:lor. 1987.
11. Americanc&+ of obsietlicians and Gynecok+s Shate$as and op lions for impovlng xce% to maternal heah care:the obstebicia”-gqn~*t as advocate,Washington,DC Author, 1988.
FIG’JRE 3. Mostfrequentlycitedcontributions cetified nurse-midwives couldmakem run, Arkona. locate in rural awas view physicians as a major barrier. Ceriified nursemidwives who actually work in rural meas identify both physkians and lack of hospital admitting privileges as barden. Even if physicians welcomed CNMs, however. courage
the same
forces that
physicians
obstehics wwld
from
dis-
practicing
disoxua~.~ them from
providing backup servic& for CNMs. These forces include fear of ltabilitv. the closure of rural hospitals, closure of matzmity pitals.
and &e
units in mral hos-
In addition, physicians who
provide maternity care may be discouraged from providing backup for CNMs because the cost of their malpractice insurance could increase 01 because
their
insurance
companies
would not allow it (19). A system to facilitate physlcian backup
for CNMs.
joint physician/nurse-midwlfey
pm-z-
ttce, and accessto hospital privileges must be implemented before CNMs can realize their full potential ternal and infant
as ma-
health care pravtd-
as in both rural and urban areas of the United States.
REFERENCES 1 U.S. congress.Office of Technoloav AssessmentHealth care in rural A&ca (OTA-H-4%1 Washmgton.DC: U 5. Governmenthinting Oflice. 199D. 2. DeFriese G. RichettsT. priman/ health care in rural areas:ai, agendafor research.Health Sew Res 1989:23:93174. 3. BassRI_. Paulman PM. The rural preceptorship az a factorin the resider,n/ s&&an the Neb,&a expmience.J Fam Pmct 198?&17:71.%19. 4. NorrisTE, Nonis SB. The eifat of a rural preceptorship duringresidencyon pmcticesiteselectionand interestin rural practice.J Fam Pmct 1988:27541-4. 5. StelnwaldB. Stehwald C. The effeet of preceptorshipand mm, bafn%g progmmon physicians’practicekcatin de&ion. Med ‘Cal-e1975;13:219-29. 6. Heald KA. Caaper JK. C&man S. Choke of locationof practiceof med. ical vhool graduates:analysisof tv.vsurveys Santa Monica (CA): Rand Cor~o mtior: R.l47iwEW, 1974. 7. Cooper JK. Heald K, Sam& M, Coleman s. Rural or urban practice:faLto,s influencingthe locatian de&on of primary care physicians. lnquily 1975;12:1%24. 8. Gordon lT. Denton D. The rektionshipafrum,clinicalrotationstowherr RNs ~rach;ce. J RuralHealth lY92;8:2%304. 9. Aao”a Department of Health Services,Office of Flaming and Health Status Monitoring Clasing the decz&:
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12. Gadon R, McMuUenG. WeissB, Nichok AW. The effectof malpmctkeIiability on the deliver9of rural obnphical care.J Rural Health 1987:3:7-13. 13. Gcfda” R, Hit5 B. WaltersJ. Decliningavail&i of phy+zian &&et& sem%ein rural A&cna and medicaf malp~e&sws Pap+rpresentedatthe 117th Annual Meeting of the American PublicHe&hAx&,&,n,Cbii,
1989
Oci 24. 14. H&es
D,
Rosenbarn
S. An
overview of maternal and infant he& wm%cesinmmlAmeria.JRuralHeakb
1989;5:29!!19. 15. Rorenblatt R, Whelan A, Hart f,. Rural obstetrical access in WashiGQtorl sia,e: have we attainedeq”ilibrium?-Seattle:WAMl Rural Health ResearchCenter. 19% 16. ZpsnisKArqwta~pnmatafe~ta~cme. low bIrthweight and infant mortality. Phoenix Altmna oepamnent of Healtb ties. Division of Fzmtly Health Serukes, 1990. 17. Genten J. MI&, C. Artzona health status and vital statisfics 19.53 Phoenix Atina Deparmwt of He& Sezvicw Office of Planning and Health Status t.ionitoliq> 1990 18. Gal!agher K. Gordon 1 Study of the avaifabilityofobstehicaland&erprimay care seties in underserved Arizona Tucson: Rural Health Mfice, De@men* of Fam$ and Community M&?&e, University of A&OM College of Medtcine. 1990. 19. Gordon R. The effecls of malpm&e inswaxce on certified nurse midwives, the case of rural Aiizona J Nurse Midwifery 1990;3599-106. 20. He&b
Reswrcet
and
Setice
Admin&ration. A stxtb reportto the Residedand Congwson the statusof be&h personnel in the United Stata Rockvtlle
33
[MD): Bureau of Health Manpower IDHHS). 1988. 21. Institute of Medkine. Preventing low bihweight. Washington. DC National Academy Press. 1985 22. National Commission to Prevent infant Mortality. Death before life: the tragedy of infant motility. Washington, DC: Author. 1988. 23. Reid M, Morris J. Petinata, care and cart-effectiwnw: changes in health expenditures and bkth outcanes f&wing the establishment of a nurse-mldwlfe prcgmm. Med Care 1979:17:491500.
84
24. Rooks J, Weatherby N. Ernst E, Staoleton S. Rosen D. RosenfieldA. Out-
Joumaf of Nurse-“kh&y
practice in a rural setting. J Nurse Midwifew 1988:33:86-92. 27. Poe D. The FNS medical diwc&a-the historical innovation that has assuredthe best in rural health care. Front Nun Sen, Q Bull 1985@:20-4. 28 Vamey H. Nurse-midwifey. Bos@on: Bfackw”XientifrPubIicatioubliea6am 1987. 29. Adams C. Nurse midwifery pmcnce in the United States. 1982 and 1987. Am J Public Health 1989;79:103%9. 30. Bavter L. Nurse-midwifery in a mraf setting: a different pelspectiv’ve. J Nurse Midwifely1989;34309-10.
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1993