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way. These funds provide incentives to students to enter these nursing programs, especially helping to finance minority students in need of education stipends.

Directors of all thirty educational programs are also seeking additional sources of funding -- from state governments, from private foundations and from faculty generating service dollars. This later practice is dependent on the state laws under which a CNM is licensed, as well as the CNM's ability to gain hospital privileges -- barriers to practice which still restrict nurse-midwifery in some areas of the country. In fact, the availability of this option for nurse-midwifery faculty is much more limited than for faculty at medical schools. Faculty are further limited since they provide care for underserved patients and this type of health care service cannot subsidize the educational programs.

Return on Investment

The federal funds that have been spent over the past ten years on nurse-midwifery education have been repaid many times over by CNM's services to the poor and underserved in the United States.

Today, nurse-midwifery practices exist in all 50 states, and in many developing countries around the world. Certified nurse-midwives can be found in hospital settings, in clinics, and in privately owned birthing centers. Fortunately the tradition of providing care to the poor continues. This is especially important in light of information which indicates that obstetricians are caring for smaller numbers of Medicaid clients.

A Safe Cost Effective Alternative

Over the years nurse-midwives have maintained a superb record of safety and client satisfaction. Nurse-Midwifery is also a highly cost-effective approach to health care delivery. Hospital stays tend to be shorter and care regimens less technologically complex when not medically necessary with nurse-midwife assisted deliveries.

A Significant Contribution To Healthier Births

One of the maternal and infant health objectives set by Healthy People 2000 is to : "Increase to at least 90 percent the proportion of all pregnant women who receive prenatal care in the first trimester of pregnancy". This objective is imperative since early, high-quality prenatal care is critical to improving pregnancy outcomes and reducing neonatal mortality.

A number of studies have shown that care by nurse-midwives increases utilization of prenatal care facilities, and that such care lowers the risk of low birthweight, prematurity and neonatal death. Recent reports by the National Academy of Science's Institute of Medicine, the Southern Governors' Association Task Force on Infant Mortality and the Children's Defense Fund highlight nurse-midwives' outstanding contribution to preventing low birthweight.

Another objective stated by Healthy People 2000, Increase to at least 60 percent the proportion of primary care providers who provide age-appropriate preconception care and counseling also can be achieved by using nurse-midwives as providers. Certified nurse-midwives endure that their patients are healthy prior to pregnancy, there by reducing the risk of problem pregnancy and poor outcome. We care for all women regardless of income, social status, or ethnic background.

Present Needs

At this time we are requesting $20.000.000 to meet the educational needs of nurse-midwives/nurse practitioner programs. Presently, only nine nurse-midwifery programs are being funded. The additional funding requested is only enough to fund 46 additional new nurse-midwifery/nurse practitioner programs. These funds will help afford student scholarships as well as provide educational supplies, equipment and help pay for faculty salaries.

The program at Georgetown University graduates 15 students annually.


The American College of Nurse-Midwives urges Congress to appropriate funding levels adequate for the educating of sufficient numbers of nurse-midwives and other nurses with advanced nurse education.

Certified nurse-midwives have a rich tradition of providing access to care for the poor and other underserved, populations. This service more than compensates for the federal funding which has supported the educational programs in the past. Continued growth of nurse-midwifery in the United States will help address two serious national health problems -- the persistently high rate of low birthweight and premature births, and the rising cost of health care.


Mr. Chairman and members of the Subcommittee, thank you for the opportunity to appear before you. In my brief testimony I would like to provide some background as to what makes St. George's such a unique medical school as well as discuss some recent developments that impact our Finally, I would like to recommend some changes in federal law which would not only benefit the St. George's University School of Medicine but the health care of our nation as well.


The St. George's University School of Medicine has a growing history of medical educational success. Since being founded in 1976, 1,651 students have graduated with degrees in medicine, many who return home to the United States to practice in medically underserved areas. In fact, in many inner city teaching hospitals that treat and care for great numbers of poor and indigent patients, 80-90% of residency positions are filled by graduates of international medical schools. In the United States there would be a significant problem caring for indigent and poor patients if not for residency slots being filled by eager graduates from non-U.S. schools such as St. George's.


Journal of the American Medical Association in its January 18, 1985 issue reported that the St. George's University School of Medicine had the highest initial pass rate of all the leading international medical schools in the world on the U.S. qualifying Examination (the ECFMG). As each class at St. George's finishes its second year of medical education, approximately one-third of that class qualifies and transfers to U.S. medical schools to complete their education.


Mr. Chairman, several developments have occurred during the

years that have had a very positive impact on st.

George's, and the students who attend this developments have enabled St. George's to comprehensive and complete medical education.



(1) The New York and New Jersey State Departments of Education have approved plans that allow the placement of third and fourth year students from St. George's to begin clinical clerkships at several area teaching hospitals.

eligible schools.

(2) In 1986, Congress reaffirmed during the Higher Education Act that Guaranteed Student Loans should be available to students attending foreign institutions with a comparatively high pass rate on the examination administered by the Education Commission on Foreign Medical Graduates. St. George's, by virtue of its pass rate is one of those

Council, which

institution. These

offer an even more

(3) In 1986, Congress assembled the Council on Graduate Medical Education to examine key issues related to federal policy and Graduate Medical Education. In July of 1988, the is comprised of a representative sample of U.S. medical education experts, concluded that foreign medical school graduates should not be treated separately or equally, and that selection into GME should be based on individual competence, not group or geographic association. The Council also stated that if the government had no rational basis for denying public funds for graduates of foreign schools, that it could be considered constitutionally discriminatory.

School graduates.

They are:


The National Board of Medical Examiners has changed their long-standing policy of administering different examinations Graduates vs. Domestic Medical

to International Medical

graduates of international



domestic medical schools will take the same licensing exam, known as the United States Medical Licensing Examination, thereby allowing their skills to be compared on an equitable basis.

The American Medical Association, in concert with the Educational Commission for Foreign Medical Graduates and the Federation of State Medical Boards, is instituting a new national physician credentials verification service. This new repository for medical credentials will aid in the state-to-state licensure by endorsement process by limiting duplicative state document requirements for all practicing physicians. By authenticating and verifying medical degrees and documents, this new clearinghouse will enable international medical graduates to more easily gain approval by State medical licensing boards who fear fraudulent documentation.

Mr. Chairman, I bring these examples to your attention to demonstrate that things have been improving and that some discriminatory barriers have begun to come down. However, there is no mistaking that discrimination toward graduates of foreign medical schools is common, particularly in the areas of residency position acceptances, as well as in the areas of licensure, jobs, hospital promotions, privileges and peer reviews.

Several challenges still remain within a number of the programs funded by your subcommittee. The President's budget for FY'91 proposes a large cut in Health Education Assistance Loans (HEAL) which provide loans to students seeking a health professions career. HEAL loans are an important mechanism for students attending medical school. The program should not be cut, and in fact should be expanded. HEAL loans are not available to an American student who attends a foreign

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