Ebony Marcelle, the director of midwifery at Community of Hope in Washington, D.C., started her doctoral degree after more than a decade of working as a midwife.
A Georgetown University School of Nursing graduate, Marcelle got her master’s degree in midwifery at Philadelphia University and started working in clinical leadership and advocating for issues concerning Black maternal health. But she wanted to go even further to advance systemic change at a policy-making level.
Marcelle earned a Doctor of Nursing Practice (DNP) at Frontier Nursing University, one of the oldest and largest nursing schools in the country. She quickly noticed a change in how she was perceived at conferences, congressional briefings, policy hearings and other events.
“This is not just about getting that seat at the table. It’s about being viewed differently once you get to that table,” Marcelle said.
Advancing generational wealth in maternal care
We have a midwifery shortage in the United States that has been due to multiple factors, but the underinvestment in educational programs for midwifery at all levels is one of them.”
UC San Francisco’s nurse-midwifery program received approval this week by the Accreditation Commission for Midwifery Education, which allows the School of Nursing to start admitting the first midwifery students to the new DNP track. The school will start accepting applications on April 18 for the program that begins in June. The application deadline is May 18.
The nursing school has already begun accepting applications in other specialties for its first class of students entering with a Bachelor of Science in Nursing (BSN) degree who will go straight into the DNP program. UCSF’s shift to the BSN-to-DNP pathway has been in the works for years, with the transition officially starting in 2020.
The decision to redesign UCSF’s advanced practice nurse specialties, including midwifery, from the Master of Science to the DNP aligns with a national shift to clinical doctorate-level education.
This standard was endorsed by the American Association of Colleges of Nursing in 2004, and the midwifery DNP has already been implemented by about two dozen nursing programs including Columbia University, the University of Tennessee, University of Washington, Oregon Health & Science University, University of Illinois and University of Minnesota.
“UCSF is steadfast in our commitment to train nursing leaders to transform health and the delivery of care, particularly in the communities we serve in California that lack access to high-quality care,” said Carol Dawson-Rose, PhD, RN, FAAN, dean of the UCSF School of Nursing and associate vice chancellor for Nursing Affairs. “It is imperative that we expand doctoral preparation to meet the academic standard of nursing and ensure that our graduates remain at the top of the field.”
While the shift to the DNP program affects all of UCSF’s nursing specialties – adult gerontology, family, and psychiatric mental health – more concerns have been raised about how the change impacts the midwifery program.
Midwifery and maternal health care issues are steeped in concerns around equity, particularly for women of color and people from rural and poor communities. Black women in the U.S. have the highest maternal mortality of any racial or ethnic group, with death rates that are more than two-and-a-half times that of white women.
In California, which has one of the lowest maternal mortality rates in the country, the disparity among Black mothers persists at similar levels, often regardless of income and educational status. Experts attribute these inequities to a range of largely preventable factors including chronic stress created by discrimination, lack of access to quality health care and unhealthy community conditions.
But rather than simply improving those conditions one birth at a time, UCSF is positioning itself to train the future leaders in nurse midwifery, equipping them to help make systemic changes in maternal care that will be passed onto successive generations, akin to passing on generational wealth.
The push for systemic change
Nikia Grayson, who joined the UC San Francisco’s School of Nursing faculty last year as co-specialty director of the school’s midwifery program, wasn’t surprised that UCSF was making the shift from offering masters-level training to a three-year DNP practice.
Grayson, who received her DNP from the University of Tennessee Health Science Center in 2016, was surprised it took so long.
“Nursing has been moving in this direction for more than 20 years,” said Grayson, DNP, MSN, MPH, MA, CNM, FNP-C, FACNM, who also serves as the chief clinical officer of Choices Center for Reproductive Health in Memphis, Tennessee.
For Grayson, a Black midwife and advocate for equity in maternal health midwifery, being prepared at the doctoral level has positioned her to be a leader in health care in Tennessee.
“It’s helped to give me the skills I need to influence policy, advocate for systemic change and take on executive-level roles,” said Grayson, who has spoken at conferences, policy hearings and, in 2021, gave a TED Talk on how Black midwives can help fix the maternal health care system.
To Grayson, that meant pursuing the educational and career opportunities needed to help improve maternal health conditions for women of color, and that included joining UCSF’s faculty. “UCSF’s mission resonates deeply for me in integrating reproductive justice into health care,” she said. “I’m equipping myself to mentor and teach that to future generations of nurses and midwives.”
Many pathways to midwifery
In California, nearly 1,300 nurse midwives are licensed to provide care, a number that has remained fairly stable between 2017 and 2023, according to the California Health Care Foundation.
Experts agree there simply aren’t enough midwifery education programs in the U.S. to meet the growing demand for services, particularly in rural areas where there are not enough maternity care providers. That’s also true in California. The only licensed midwifery program in California closed at the end of 2022, and UCSF’s transition to DNP leaves California State University Fullerton as the only program in the state providing masters-level midwifery education.
We need midwife leaders at every level.”
“We have a midwifery shortage in the United States that has been due to multiple factors, but the underinvestment in educational programs for midwifery at all levels is one of them,” said Monica McLemore, PhD, MPH, RN, FADLN, a former associate professor at the UCSF School of Nursing who is now a visiting professor at New York University's Rory Meyers College of Nursing.
To McLemore, UCSF’s decision to shift to the DNP pathway makes sense, given the educational options the school could choose. But McLemore contends it’s expensive and difficult to fund enough appropriately trained faculty to teach two different tiers of curricula.
McLemore recommended that more nursing programs in California and across the country offer midwifery programs at different levels, be it at a professional, master’s or doctoral level. She suggested universities and nursing programs work with philanthropic organizations to help fund midwifery programs.
A growing number of advanced-practice nursing programs are being offered online, including Frontier Nursing University, Georgetown University, George Washington University, University of Cincinnati and University of Colorado Anschutz Medical Campus. New programs could be started, most likely as part of an existing nurse training program.
New options for leadership in maternal health
UCSF’s previous program, Master’s Entry Program in Nursing (MEPN), took 10 quarters over three years, with a summer break, while the BSN-to-DNP pathway will take 12 consecutive quarters over three years, or seven quarters as a post-master’s program of study.
UCSF’s midwifery program will offer financial aid and opportunities that make the cost comparable to the previous program and continue to have 10 to 12 graduates a year.
The number of nurse midwives UCSF will graduate into the workforce will remain the same after the shift, with little difference in the time and cost of the program.
But these graduates will now have the benefit of having a doctoral-level education – one that not only prepares them to provide the highest level of care and train other nurse midwives but also positions them to be the health care leaders who can help reshape the policy landscape for maternal health in California and nationwide.
“We need midwife leaders at every level,” said Amy Law, PhD, MS, CNM, an assistant professor and co-specialty coordinator of the midwifery department in UCSF’s Department of Family Health Care Nursing. Law, who was also hired at UCSF last year, received her PhD in nursing at UCSF and continues to work at Kaiser Permanente as a certified nurse midwife.
“UCSF is and always will be committed to educating and fostering strong leaders to impact maternal-child health overall and address disparities related to racism and social drivers of health,” she said. “We need midwives’ wisdom and perspective in individual care but also at the systemic levels – locally, nationally and globally. The DNP midwifery degree is a natural fit for the goals.”
