Certified Nurse-midwives Research Articles

Formulating Evidence‐Based Guidelines for Certified Nurse‐Midwives and Certified Midwives Attending Home Births

Implementing national home birth guidelines for certified nurse-midwives (CNMs) and certified midwives (CMs) in the United States may facilitate a common approach to safe home birth practices. Guidelines are evidence-based care recommendations for specified clinical situations that can be modified by individual providers to meet specific client needs. Following a review of home birth guidelines from multiple countries, a set of home birth practices guidelines for US CNMs/CMs was drafted. Fifteen American Midwifery Certification Board, Inc. (AMCB)-certified home birth midwives who participate in the American College of Nurse-Midwives (ACNM) home birth electronic mailing list considered the use of such a document in their practices and reviewed and commented on the guidelines. The proposed guidelines addressed client screening, informed consent, antepartum care, routine intrapartum care, obstetric complications and hospital transports, postpartum care, neonatal care, gynecologic care, primary care, peer reviews, recordkeeping, and physician collaboration. The reviewers had varying assessments as to whether the guidelines reflected international standards and current best evidence. The primary concern expressed was that an adoption of national guidelines could compromise provider autonomy. Incorporation of evidence-based guidelines is an ACNM standard and was recommended by the Home Birth Consensus Summit. Clinical practice guidelines are informed by current evidence and supported by experts in a given discipline. Implementation of guidelines ensures optimal patient care and is becoming increasingly central to reimbursement and to medicolegal support. A set of practice guidelines based on current best evidence and internationally accepted standards was developed and reviewed by an interested group of US CNMs/CMs. Further discussion with home birth midwives and other stakeholders about the development and implementation of home birth guidelines is needed, especially in light of this project's finding of less support for national home birth guidelines among the reviewers subsequent to versus prior to their review of the draft guidelines.

The 2012 American College of Nurse‐Midwives Core Competencies for Basic Midwifery Practice: History and Revision

The American College of Nurse-Midwives (ACNM) Core Competencies for Basic Midwifery Practice, approved in 2012, (hereafter referred to as Core Competencies) outline the knowledge, skills, and abilities that can be expected of new certified nurse-midwives (CNMs) and certified midwives (CMs). The Core Competencies are standards for midwifery education, and the document is an important guide for midwifery practice and policy. As a part of the 2012 revision, the Basic Competency Section of the ACNM Division of Education reviewed a variety of national and international documents to ensure that the basic education of CNMs/CMs is consistent with the practice of midwives in the United States and internationally. Few substantive changes were made to the document, but several areas were adjusted and clarified. New graduates continue to be prepared by midwifery education programs to provide safe, evidence-based midwifery care to women across the lifespan, well newborns up to 28 days, and sexual partners of women diagnosed with sexually transmitted infections.

Improving Care for Women with a History of Gestational Diabetes: A Provider Perspective

To identify perceived roles with regard to care for women with gestational diabetes mellitus (GDM) history and resources for improving care among women with a history of GDM from the perspective of obstetrician/gynecologists (OB/GYNs), certified nurse midwives (CNM), family practitioners, and internists. In 2010, a survey was sent to a random sample of OB/GYNs, CNM, family practitioners, and internists (n=2,375) in Ohio to assess knowledge, attitudes, and postpartum practices regarding diabetes prevention for women with a history of GDM. A total of 904 practitioners completed the survey (46%). Over 70% of CNMs strongly agreed it is part of their job to help women with GDM history improve diet and increase exercise, compared with 60% of family practitioners/internists and 55% of OB/GYNs (p<0.001). More OB/GYNs and CNMs identified a need for more local nutrition specialists and patient education materials, compared with family practitioners/ internists. Between 60 and 70% of OB/GYNs and CNMs reported lifestyle modification programs and corresponding reimbursement would better support them to provide improved care. Health care providers giving care to women with GDM history have varying perceptions of their roles, however, there was agreement on resources needed to improve care.

Which Family Physicians Work Routinely With Nurse Practitioners, Physician Assistants or Certified Nurse Midwives

Facing rising numbers of insured with implementation of the Affordable Care Act, policy makers are interested in building teams of providers that can accommodate a growing demand for primary care services. Nurse Practitioners (NPs), Physician Assistants (PAs), and Certified Nurse Midwives (CNMs) already augment the physician workforce, particularly in rural areas. Our objective was to determine what physician and areal-level characteristics were associated with working with NPs, PAs or CNMs. The sample consisted of a convenience sample of physicians through the American Board of Family Medicine (ABFM) website in the fall of 2011. We linked these data to demographic and practice information collected by the ABFM and with provider information supplied from the National Provider Identifier file aggregated at the Primary Care Service Area level. Hierarchical logistic regression models were used to determine variables associated with working with NPs, PAs, or CNMs. Of the 3,855 family physicians in our sample, 60% reported routinely working with NPs, PAs, or CNMs. In regression analysis, characteristics positively associated with working with NPs, PAs, or CNMs were providing gynecological care (Odds Ratio = 1.23 [95% confidence interval, 1.06-1.42]), multispecialty group practice (OR = 1.72 [1.36-2.18]), any rural setting, and higher availability of PAs (OR = 1.40 [1.10-1.79]). Restrictive NP scope of practice laws failed to reach significance (OR = 0.86 [0.71-1.05]). This study suggests that the number of family physicians routinely working with NPs, PAs, and CNMs continues to increase, which may allow for improved access to health care, particularly in rural areas.

Home Birth in North America: Attitudes and Practice of US Certified Nurse‐Midwives and Canadian Registered Midwives

Scope of practice, competencies, and philosophy of maternity practice are similar among midwives in the United States and Canada. However, there are marked differences in intrapartum practice sites between registered midwives (RMs) and certified nurse-midwives (CNMs). This study linked data from 2 national surveys: 1) a 2007 survey of CNM members of the American College of Nurse-Midwives (n = 1893); and 2) the Canadian Birth Place Study of maternity providers, including RM members of the Canadian Association of Midwives (n = 451) to compare the demographics, practice experience, and attitudes to home birth between these 2 types of North American midwives. A Provider Attitudes To Planned Home Birth scale-international (PAPHB-i) was developed for this analysis. Descriptive and bivariate analyses are presented. Educational exposure to planned home birth varied greatly when comparing CNMs and RMs, as did practice patterns regarding continuity of care, primary and gynecologic care, and involvement with research and teaching. Registered midwives were almost 4 times more likely than CNMs to have practiced in the home (99.1% vs 26.0%). Certified nurse-midwives scored significantly lower than RMs on the PAPHB-i scale (36.5 vs 41.0), indicating less favorable attitudes toward home birth overall. Certified nurse-midwives were less confident than RMs in their management skills for home birth practice. Age, exposure to planned home birth during midwifery education, and practice experience in the home setting emerged as significant covariates of attitudes toward home birth. Significantly more RMs and CNMs with home birth experience expressed concerns about disapproval of hospital-based peers, but they were significantly less likely to agree that midwives face other systemic barriers than CNMs with no home birth experience. Differences in favorability toward and confidence with practice during planned home births among CNMs and RMs were predicted associated with differences in educational and practice exposure to planned home birth. We recommend that clinical experiences and theoretical content about planned home birth and preparation for multidisciplinary collaboration across settings be integrated as essential and required components of all health professional education programs.

Improving Maternal and Infant Health through CenteringPregnancy: Results of a 2‐Year Retrospective Chart Review Using a Matched Comparison Design

ObjectiveHealthy People 2020 goals include reducing infant mortality and morbidity associated with pregnancy. CenteringPregnancy is a model of health care delivery that unifies health assessment, education, and support into a group setting that has been shown to improve prenatal care compliance, prenatal health knowledge, and prematurity.Research QuestionIs there a difference in select maternal health indicators and pregnancy outcomes between women participating in CenteringPregnancy and traditional care?MethodsAn analysis was conducted comparing CenteringPregnancy participants with a matched comparison group (traditional care). Data were collected through retrospective records review. Institutional review board approval was obtained from Western Michigan University and Borgess Medical Center prior to data collection. For the period of data collection (January 2010 through April 2012), 173 CenteringPregnancy participants were identified and a comparison group of 170 traditional certified nurse‐midwife (CNM) care clients were selected matched on race, age, and insurance status. Additional maternal data collected included prior pregnancies, height, and prepregnancy weight. Prenatal variables included number and timing of prenatal care visits, weight gain, and smoking status. Intrapartum variables included mode of birth and gestational age. Postpartum data were collected regarding attendance at a 6‐week postpartum visit and breastfeeding.ResultsThere was a significant between‐groups difference in gestation at first prenatal visit (11.8 weeks for traditional care vs 10.3 for CenteringPregnancy, P = .031). There was not a significant difference in mean number of prenatal visits (14.2 for CenteringPregnancy vs 13.4 for traditional care, P = .266). There was not a significant difference in rates of smoking at pregnancy diagnosis (26% [n = 45] of CenteringPregnancy vs 30% [n = 49] of traditional care); however, 69% (n = 31) of the women in the CenteringPregnancy group quit with pregnancy diagnosis versus 18% (n = 9) of the traditional care group (P &lt; .001). Additionally, 50% (n = 7) of those still smoking quit during CenteringPregnancy versus only 8% (n = 3) during traditional care (P &lt; .001). There was no difference in pre‐pregnancy weights or weight gain between groups, with only 28% of traditional care and 25% of CenteringPregnancy participants gaining the optimal amount of weight. There was no difference in mean gestational age at birth (39.3 weeks for CenteringPregnancy vs 39.5 weeks for traditional care) or rates of preterm births (5.8% in CenteringPregnancy vs 5.9% in traditional care). There were no differences in cesarean rates (17% for CenteringPregnancy vs 14% for traditional care, P = .443). Both groups had high rates of attendance at their 6‐week postpartum visit (92% for CenteringPregnancy vs 88% for traditional care, P = .243). CenteringPregnancy participants were more likely to initiate breastfeeding (79% vs 60% for traditional care, P &lt; .001) and more likely to still be breastfeeding at the 6‐week postpartum visit (65% vs 45% for traditional care, P &lt; .001).ConclusionIn this study, CenteringPregnancy demonstrated promise in reducing smoking rates during pregnancy and improving breastfeeding rates. This study also demonstrates that optimal weight gain guidelines must be addressed with women during pregnancy regardless of type of prenatal care. Findings from this study must be viewed in light of the self‐selection bias. Despite our attempts to control for variance by utilizing a matched comparison design, women who chose CenteringPregnancy initiated prenatal care earlier and also were more likely to quit smoking prior to onset of prenatal care than those who chose traditional care.

Findings From the Analysis of the American College of Nurse‐Midwives’ Membership Surveys: 2009 to 2011

The American College of Nurse-Midwives (ACNM) Core Data Survey is an annual membership survey that collects demographic and selected workforce data about certified nurse-midwives (CNMs), certified midwives (CMs), and students enrolled in midwifery education programs accredited by the Accreditation Commission for Midwifery Education. These data are aggregated and published every 3 years. This article presents findings from the analysis of membership data for the years 2009 to 2011. An online survey is sent annually to all ACNM members who provide ACNM with an e-mail address. The survey instrument for 2009 to 2011 focused on 5 categories: demographics, certification, education, employment, and licensure except for 2011, in which licensure data were collected separately. ACNM members responding to the surveys during 2009, 2010, and 2011 continued to remain predominantly white and female. The average age of CNMs/CMs in 2011 was 51.2 years. The majority had a master's degree as their highest degree, and 9.3% had a doctoral degree. Approximately two-thirds of respondents in each of the 3 survey years identified attendance at births as one of their primary responsibilities. Very little change in diversity was observed over the 3 survey years. The number of CNMs earning the doctor of nursing practice degree is increasing, whereas other doctoral degree categories remain stable. The majority of CNMs/CMs continue to identify a broad domain of clinical midwifery practice as their primary responsibility in their employment. The majority of respondents attend births, but the proportion has been decreasing slightly over time. Salaries for midwives continue to rise, but the reasons for this are unclear.

Increasing Certified Nurse‐Midwives’ Confidence in Managing the Obstetric Care of Women with Female Genital Mutilation/Cutting

In response to an increase in the number of women who immigrate to the United States from countries that practice female genital mutilation/cutting (FGM/C; infibulation), US clinicians can expand their knowledge and increase confidence in caring for women who have experienced infibulation. This article describes a comprehensive education program on FGM/C and the results of a pilot study that examined its effect on midwives' confidence in caring for women with infibulation. An education program was developed that included didactic information, case studies, a cultural roundtable, and a hands-on skills laboratory of deinfibulation and repair. Eleven certified nurse-midwives (CNMs) participated in this pilot study. Participants completed a measure-of-confidence survey tool before and after the education intervention. Participants reported increased confidence in their ability to provide culturally competent care to immigrant women with infibulation when comparisons of preeducation and posteducation survey confidence logs were completed. Following the education program and the knowledge gained from it, these midwives were more confident about their ability to perform anterior episiotomy and to deliver necessary care to women with FGM/C in a culturally competent context. This education program should be expanded as more women who have experienced infibulation immigrate to the United States.

The Center for Holistic Birth: An Organized Step Back in Time When Birthing Worked

<h2>Childbearing Poster Presentation</h2><h3>Purpose for the Program</h3> When pregnancy is allowed to progress naturally, most of the time a woman will give birth to her newborn with no complications. However, in the current healthcare climate, a woman is faced with many interventions during pregnancy that are changing the climate of birth in many institutions across the country. Medical professionals order inductions and other interventions, patients do not know what these inductions and interventions are for, and nurses are caught in the middle. How do we change the current climate? <h3>Proposed Change</h3> To incorporate an evidence‐based holistic approach to the healthcare climate by using Jean Watson's Nursing Theory to affect patients and remind them of their innate abilities. <h3>Implementation, Outcomes, and Evaluation</h3> After meeting with departments throughout the institution to discuss the foundation of the program, referrals from various sources started. Patients will meet with the certified nurse‐midwife (CNM) multiple times during their pregnancies depending on their gestations, free of cost. They discuss resources for education and formulate a birth path. Meetings also cover different birthing options and practices and allow patients to explore what is right for them. After the last meeting before delivery, the CNM writes up a summation of the meetings that took place with the patient and attaches a copy of the patient's birth path. This information is attached to the patient's prenatal chart, which allows staff the opportunity to view it at the time of the patient's admission. <h3>Implications for Nursing Practice</h3> Holistic birth is not equated with natural birth; however, as the program has grown it has become increasingly apparent that women want to experience the most they can from their deliveries, regardless of what drew them to the program initially. The epidural and cesarean delivery rates are significantly lower in the program, and another important trend has risen to the surface. Women who participate in this program feel empowered to ask questions, challenge the status quo, and be active participants in the decisions regarding their births. All of this has culminated into a satisfying, rewarding experience, regardless of the outcome.

Abortion-care education in Japanese nurse practitioner and midwifery programs: A national survey

While various reports have been published concerning ethical dilemmas in nursing and midwifery, and while many nurses and midwives struggle with the conflict between personal feelings raised by abortion and the duties of their position, few studies investigate the extent and conditions of abortion-care education for registered nurses (RNs) and certified nurse-midwives (CNMs) in Japan. To describe Japanese abortion-care education programs and to investigate program directors' or other relevant persons' perceptions of abortion-care education. Descriptive study was used to determine the extent of abortion-care education programs and the respondents' perceptions of abortion-care education. All 228 Japanese nursing and/or midwifery schools were invited to participate in the study. The response rate was 33.8% (n=77). Response rate varied by program type: 18.4% (n=45) for nursing programs and 29.0% (n=32) for midwifery programs. A confidential survey requesting information about curricular coverage of ten reproductive health topics related to abortion was mailed to program directors. The results show that the majority of CNM and RN programs surveyed offer didactic exposure to instruction in family planning and contraception, emergency contraception, legal considerations, and possible medical complications. However, few programs offer clinical exposure to all 10 topics. Of the respondents, 36% reported that lack of time and the low priority given to abortion-care education were issues of curriculum priority. As for educational materials, few textbooks or guidebooks exist on abortion care in Japan, and most educators use general nursing textbooks to cover this topic. Regardless of interest in or intention to provide abortion services as part of their practice, all providers of abortion-care education need to be knowledgeable about the full range of reproductive health options, including family planning and abortion, and to be able to convey this information to clients.

Most Family Physicians Work Routinely With Nurse Practitioners, Physician Assistants, or Certified Nurse Midwives

The U.S. physician workforce is struggling to keep pace with the demand for health care services, a situation that may worsen without efforts to enhance team-based care. More than half of family physicians work with nurse practitioners, physician assistants, or certified nurse midwives, and doing so helps ensure access to health care services, particularly in rural areas.

Improving Satisfaction with Care and Reducing Length of Stay in an Obstetric Triage Unit Using a Nurse‐Midwife‐Managed Model of Care

A quality improvement project was initiated at a tertiary-care center in a suburban area of the northeastern United States to determine whether length of stay and patient satisfaction in an obstetric triage unit could be improved by using a certified nurse-midwife (CNM) to manage and organize care in the triage unit. Patient satisfaction was measured using a previously validated instrument that consisted of 6 items using a 6-point Likert-type scale. The items measured patient satisfaction with: wait time for provider, information given, amount of time spent with provider, length of visit, overall care received, and overall triage experience. Patient satisfaction was measured before (n = 37) and after implementing CNM-managed care (n = 66) in an obstetrical triage unit. Length of stay in the triage unit was measured during standard care (n = 121) and after the implementation of CNM-managed care (n = 151) by recording the number of minutes women spent in the triage unit. Participants in the CNM-managed care group reported increased patient satisfaction with care in 5 of the 6 aspects of satisfaction that were measured, including wait time for provider (P = .01), time spent with provider (P = .01), length of visit (P = .04), overall care received (P = .04), and overall triage experience (P = .01). The length of stay was significantly shorter for the women in the CNM-managed group (mean = 94.7 minutes; standard deviation [SD] 50.1) than for the women in the standard care model (mean = 122 minutes; SD = 66.8; P < .01). The findings from this project suggest that a CNM-managed obstetric triage unit can improve satisfaction with care during the triage experience and reduce length of stay in the triage unit.

Outcomes of Planned Home Births Attended by Certified Nurse‐Midwives in Southeastern Pennsylvania, 1983‐2008

In this study, we examined the perinatal outcomes of planned home births over a 25-year period (1983-2008) in a group of primarily Amish women (98%) attended by certified nurse-midwives (CNMs) in southeastern Pennsylvania. This was a retrospective, descriptive analysis of data (N = 1836 births) from several CNM practices. Data were abstracted for 25 items, including demographics, labor, and birth. Initially, 2 investigators abstracted 15 records to compare assessments and standardize definitions. Charts were then divided and abstracted individually by one investigator. Several relationships were examined in 2 by 2 tables using the chi-square procedure for the difference in proportions. Maternal and newborn transfers to the hospital were included in the analysis. Of the women who planned home birth for 1836 pregnancies, 1733 of the births occurred at home. Although more than one-third of the women were of high parity (gravida 5-13), rates of postpartum hemorrhage were low (n = 96, 5.5%). There were no maternal deaths. Nearly half of the maternal transfers to the hospital (n = 103, 5.6%) were for ruptured membranes without labor (n = 25, 1.4%) and/or failure to progress (n = 23, 1.3%). The neonatal hospital admission rate also was low (n = 13, 0.75%). Of the 7 (0.4%) early neonatal deaths, all were attributed to lethal congenital anomalies that are common to this population. This study is the first to describe the outcomes of planned home births in a primarily Amish population cared for by CNMs. It also adds to the literature on planned home births in the United States and supports the findings from previous studies that women who have home births attended by CNMs have safety profiles equal to or better than profiles of women who had hospital births in similar populations.

Safety of Aspiration Abortion Performed by Nurse Practitioners, Certified Nurse Midwives, and Physician Assistants Under a California Legal Waiver

We examined the impact on patient safety if nurse practitioners (NPs), certified nurse midwives (CNMs), and physician assistants (PAs) were permitted to provide aspiration abortions in California. In a prospective, observational study, we evaluated the outcomes of 11 487 early aspiration abortions completed by physicians (n = 5812) and newly trained NPs, CNMs, and PAs (n = 5675) from 4 Planned Parenthood affiliates and Kaiser Permanente of Northern California, by using a noninferiority design with a predetermined acceptable risk difference of 2%. All complications up to 4 weeks after the abortion were included. Of the 11 487 aspiration abortions analyzed, 1.3% (n = 152) resulted in a complication: 1.8% for NP-, CNM-, and PA-performed aspirations and 0.9% for physician-performed aspirations. The unadjusted risk difference for total complications between NP-CNM-PA and physician groups was 0.87 (95% confidence interval [CI] = 0.45, 1.29) and 0.83 (95% CI = 0.33, 1.33) in a propensity score-matched sample. Abortion complications were clinically equivalent between newly trained NPs, CNMs, and PAs and physicians, supporting the adoption of policies to allow these providers to perform early aspirations to expand access to abortion care.

Gestational Diabetes Mellitus and Postpartum Care Practices of Nurse‐Midwives

Postpartum screening for glucose intolerance among women with recent histories of gestational diabetes mellitus (GDM) is important for identifying women with continued glucose intolerance after birth, yet screening rates are suboptimal. In a thorough review of the literature, we found no studies of screening practices among certified nurse-midwives (CNMs). The objectives of our study were to estimate the prevalence of postpartum screening for abnormal glucose tolerance and related care by CNMs for women with recent histories of GDM and to identify strategies for improvement. From October through December 2010, the Ohio Department of Health sent a survey by mail and Internet to all licensed CNMs practicing in Ohio. We calculated prevalence estimates for knowledge, attitudes, clinical practices, and behaviors related to postpartum diabetes screening. Chi-square statistics were used to assess differences in self-reported clinical behaviors by frequency of postpartum screening. Of the 146 CNMs who provided postpartum care and responded to the survey (62.2% response rate), 50.4% reported screening women with GDM-affected pregnancies for abnormal glucose tolerance at the postpartum visit. Of CNMs who screened postpartum, only 48.4% used fasting blood sugar or the 2-hour oral glucose tolerance test. Although 86.2% of all responding CNMs reported that they inform women with recent histories of GDM of their increased risk for type 2 diabetes mellitus, only 63.1% counseled these women to exercise regularly and 23.3% reported referring overweight/obese women to a diet support group or other nutrition counseling. CNMs reported that identification of community resources for lifestyle interventions and additional training in postpartum screening guidelines may help to improve postpartum care. CNMs in Ohio reported suboptimal levels of postpartum diabetes testing and use of a recommended postpartum test. Providing CNMs with additional training and identifying community resources to support needed lifestyle behavior change may improve care for women with recent GDM-affected pregnancies.

Advanced Practice Nursing Scope of Practice for Hospitals, Acute Care/Critical Care, and Ambulatory Care Settings

Advanced Practice Nursing Scope of Practice for Hospitals, Acute Care/Critical Care, and Ambulatory Care Settings

Advanced Practice Nursing Scope of Practice for Hospitals, Acute Care/Critical Care, and Ambulatory Care Settings: A Primer for Clinicians, Executives, and Preceptors

Advanced Practice Nursing Scope of Practice for Hospitals, Acute Care/Critical Care, and Ambulatory Care Settings: A Primer for Clinicians, Executives, and Preceptors

Reaching your Readership through the Blogosphere

Reaching your Readership through the Blogosphere

Preventing perineal tears

British Journal of MidwiferyVol. 20, No. 12 LettersPreventing perineal tearsDebra RichmanDebra RichmanSearch for more papers by this authorDebra RichmanPublished Online:16 Aug 2013https://doi.org/10.12968/bjom.2012.20.12.903AboutSectionsView articleView Full TextPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareShare onFacebookTwitterLinked InEmail View article FiguresReferencesRelatedDetails 1 December 2012Volume 20Issue 12ISSN (print): 0969-4900ISSN (online): 2052-4307 Metrics History Published online 16 August 2013 Published in print 1 December 2012 Information© MA Healthcare LimitedPDF download

JOB SATISFACTION OF CERTIFIED NURSE MIDWIVES: AN EXAMINATION

Health care providers face pressure to reduce costs and enhance patient satisfaction. One approach is to employ primary care providers such as nurse practitioners, physician assistants, and certified nurse midwives. Since there is a positive relationship between job satisfaction and patient satisfaction, positive job satisfaction on the part of providers, such as midwives, can translate into patient satisfaction. This research explores the degree of job satisfaction exhibited by certified nurse midwives. The data derives from a survey of 2000 CNM members of the American College of Nurse-Midwives. The survey captures job satisfaction factors, including interactions with physicians and nurses, job tasks, organization policies, pay, job autonomy, professional status, and job requirements and demographics. The findings reveal that the factors associated with overall job satisfaction are conditioned by midwives’ places of work. While levels of job satisfaction are high, those factors associated with it vary by workplace. Therefore, strategies designed to enhance job satisfaction for certified nurse midwives should relate to the locus of work and its environment. Keywords: certified nurse midwives (CNMs), overall job satisfaction, job satisfaction factors, places of work