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in surveillance is an important part of this strategy. Hospital infection control will present an ever increasing challenge as we' experience greater antibiotic resistance in bacteria during the next decade. New technologies in the therapy of cancer, transplantation and other life-saving procedures will result in an ever-increasing population of these patients who are especially vulnerable to hospital-acquired infections. Currently, it is estimated that 2,000,000 infections and 20,000 deaths occur annually. At least one-third of these are preventable investing in the hospital infections program of the CID now, will save millions of dollars in the future.


Support of HIV/AIDS programs of the CID is commendable. ASM recommends that the HIV/AIDS program continue to receive strong financial support, but not at the expense of other, equally important initiatives of the CID. Patients suffering from AIDS experience infections from a multitude of microorganisms, other than the human immunodeficiency virus (HIV), and in many cases these secondary infections are the cause of death. Many of these "opportunistic" microorganisms also cause serious infections in transplant and cancer patients who are also immuno-compromised. These disease problems are greatly under funded relative to HIV/AIDS programs.



We recommend an increase of $30 million in FY 1992 over the FY 1991 appropriation to the CID's operating budget. This amount is necessary to restore the resources of CID to a reasonable base level. $15 million of these funds could be used to upgrade laboratory instrumentation so that cutting edge technologies might be available for epidemiologic investigations, reference identification, and research. Funds could be used to support the installation of sophisticated epidemiologic surveillance, and reporting systems and to plan and initiate pilot research initiatives focusing on vaccine development and assessment, foodborne diseases, and newly emergent and infectious diseases. The additional $15 million could be used to support extramural programs focused on the epidemiology, diagnosis, and evaluation of prevention strategies for high priority infectious diseases.

A one time appropriation of $60 million is necessary to dedicate to CID's infrastructure. A new Microbiological Infectious Disease Lab needs to be constructed to replace the inadequate, decaying original lab first built in 1960. The ASM recommends a $60 million appropriation for the design, construction and equipment for a new Microbial Infectious Disease

Center for Prevention Services (CPS)

The ASM also recommends increased support of the CPS for its work on the prevention and control of tuberculosis (TB), sexually transmitted disease (STD), and its immunization programs. Although preventable and curable for the last four decades, TB has not been eliminated. Since 1953, 1,550,129 new cases have occurred and 238,935 people have died. The CPS should receive an additional $25 million over the FY 1991 funding level to implement detection and intervention strategies. The ASM recommends the CPS receive an additional $50 million over FY 1991 funding in order to intervene, educate, detect and treat persons with STDs. The ASM recommends the CPS receive an additional $65 million for its immunization programs, specifically $15 million for the hepatitis B program and $50 million for increased

immunization of children under the age of two. Hepatitis B virus. infection is one of the major public health problems in the U.S. An estimated 300,000 new infections occur annually, causing 75,000 cases of acute hepatitis B and 5,000 to 6,000 deaths.


The ASM recommends a $230 million increase for the budget of the Centers for Disease Control over the FY 1991 level. The ASM emphasizes the need for new funding to revitalize the Center for Infectious Diseases. The recommended $90 million increase for the CID budget is necessitated by a decade of lagging support, against a backdrop of accelerating technology and re-emerging disease patterns. The 1980's was a decade in which the CID core programs were brought to a near standstill, due to funding priorities that identified special problems such as HIV/AIDS. the 1990's, we now recognize that HIV/AIDS is additive to the other important disease elements and contributes to the traditional public health problems, but does not displace them. In the past, CDC assisted with disease problems in other countries as a courtesy. Such assistance and understanding is now a necessity to assure that these problems are controlled before they are imported.


ASM recommends the enhancement of the tuberculosis, sexually transmitted disease and immunization programs within the Center for Prevention Services (CPS) and recommends an increase of $140 million over the FY 1991 appropriation.

The revitalization of the CDC's Center for Infectious Diseases is absolutely necessary to achieve balance in the U.S. biomedical health care system. When the balance is achieved among the three elements, basic research, applied research and health care delivery programs, it will enable the government, medical and public health systems to be anticipatory rather than reactionary.



Mr. Chairman, my name is Deborah M. Bash, CNM, Ed.D. (cand.). I am the Director of the Georgetown University Graduate Program in Nurse-midwifery at the Georgetown University School of Nursing in Washington, D.C. I am pleased to report to the subcommittee on Education on behalf of the American College of Nurse-Midwives (ACNM).

It is a pleasure to speak in support of adequate funding for the Nurse Education Amendments of Title VIII of the Public Health Service Act.

A certified nurse-midwife (CNM) is a registered nurse with advanced education in midwifery who cares for women throughout the life cycle. This care involves the provision of care for women and their newborns not only during pregnancy, childbirth, and the postpartum/neonatal period, but also includes family planning and gynecological services. Certified nurse-midwives work interdependently with physicians with whom they consult and to whom they refer patients who develop complications requiring physician care.

There are approximately 4000 certified nurse-midwives in the United States. Much of the care of certified nurse-midwives has always been directed at the needs of those women with special problems in accessing childbearing and other health services. Nursemidwives are especially proud of their records in caring for pregnant women who are at risk for developing health problems because of various social and economic considerations. Pregnant teens in inner cities, young mothers in underserved rural areas of the country, Hispanic women in border states, Native Americans on reservations, and minorities seeking care in public clinics are all clients served by nurse-midwives in daily practice.

The American College of Nurse-Midwives (ACNM) is the professional organization for Certified Nurse-Midwives (CNMs) in the United States. The ACNM is autonomous from other professional organizations and speaks for its membership on all issues affecting the practice, education, legislation, economics of nurse-midwifery, and the clients we serve.

Nurse-Midwifery Educational Programs

Presently, thirty (30) of American's outstanding Colleges and Universities offer the theoretical and clinical course work in midwifery that leads to certification as a nursemidwife (listing attached). All of these educational programs have been vigorously assessed prior to accreditation by the ACNM, which is recognized by the U.S. Department of Education. Our education programs comprise three types: certified programs, masters programs and doctorate programs, and unlike many other advanced nursing education programs, operate in a variety of settings. The thirty nurse-midwifery educational programs educate over 300 nurse-midwives each year.

A new concept in nurse-midwifery education, and one that is trying to increase the numbers of nurses educated to become nurse-midwives, is now being offered. Based out of south eastern Kentucky, at the Frontier School of Midwifery and Family Nursing, the new program called the Community Based Nurse-Midwifery Education Program (CNEP) has received hundreds of requests from prospective students all over the country. This program is designed to offer greater flexibility in graduate education for self-directed adult learners who prefer independent study or who are unable to relocate to existing nurse-midwifery settings. The program is self-paced and takes a student between 18 months and two years to complete. Students are oriented at Hyden, Kentucky and return there several times during the program for intensive seminars. Upon completion of this program, courses taken may be credited toward the Master of Science in Nursing offered by the Frances Payne Bolton School of Nursing at Case Western Reserve University.

The reasons that each program can only educate and prepare approximately 10 students a year are complex. Most importantly, the education is faculty-intensive, often times demanding a ratio of one faculty member for each student (for example, when faculty are supervising students caring for women in labor and while assisting with the birth).

The students who represent the pool from which nurse-midwifery students are selected are nurses. Most schools require that the student entering a CNM program complete her/his nursing degree at a baccalaureate level prior to starting nurse-midwifery education. This means that many students already possess student loans for $20,000 or more before admission to nurse-midwifery school. These students will than need an

additional $18,000-$43,000 to complete their midwifery education. Prospective students often shy away from these financial obligations when learning that the average midwife's salary was only $36,000 in 1988. In addition, recent data from the American Nurses' Association indicates that staff nurses earn between $20,000-$26,000 a year. The pool, then, does not consist of individuals who can easily pay the high costs associated with nurse-midwifery education. Compounding this problem, part-time education in nursemidwifery is almost impossible because of the rigorous demands placed on students to be on-call for births--whenever they occur.

At Georgetown University it costs a full time student nurse-midwife approximately $22,000 for tuition and books. This does not include room and board for sixteen months. Students in the full time program cannot work and so they are without income during this period. In addition when they graduate, beginning salaries for nurse-midwives in this area are currently in the range of $38,000. Yet these students are the providers that are interested in going into inner cities and rural districts to improve the welfare of mothers and babies in this country. According to the latest report from Secretary Louis Sullivan, the nation still has along way to go to catch up to the rest of the world with regard to reducing infant mortality. Well educated and well prepared nurse-midwives can help our

nation meet these needs.

For these reasons, federal support of nurse-midwifery educational programs is vital to the continuation of these programs, even though the President's 1992 budget request eliminates all funds for the education of nurses, including nurse-midwives. Thus we appreciate this opportunity to address this issue to you today and to urge Congress to fund these programs.

Today, there is yet another new trend that is further complicating the process of educating nurses to become certified nurse-midwives--less women are selecting nursing Nursing shortage rates average almost 9% despite hospital efforts to increase nursing service. The nurse-midwifery programs are beginning to feel the shortage of nurses qualified to meet the stringent standards of the nurse-midwifery educational programs. Federal funds to the programs indirectly decrease the tuition costs while the federally-sponsored traineeships to students help to offset costs in yet another

as a career.

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