Lay midwives and the ObGyn: Is collaboration risky?

ObGyns have a long history of collaboration with their nurse- midwife colleagues—possibly one of the strongest collaborative traditions in medicine. But when lay midwives enter the picture, does collaboration become a risky proposition for you?

Lucia DiVenere, MA

In this Article

Who’s who in the midwifery world page 22

ACOG recommends high standards and clear practice “We have indeed in America medical bGyn is a risky specialty, with no agreements practitioners not inferior to the best guarantee of a perfect outcome, page 24 t n

e elsewhere; but there is probably no even with the best education, train- m O e other country in the world in which ing, and skills. Does collaboration make it there is so great a distance and so fa- riskier? Or can collaboration help you deliver manag tal a difference between the best, the high-quality care to your patients? obg average, and the worst.”

r This article explores these questions

fo 1 —Flexner report from 1910 as they relate to provision of health care in as t a collaboration with midwives—specifically, i

n Ms. DiVenere is Senior

n Director of Government certified nurse midwives (CNMs), who are Affairs at the American approved by the American Midwifery Cer- Congress of Obstetricians ry elle tification Board, and certified professional a and Gynecologists.

: M midwives (CPMs), who are not. (See the box on ti Ms. DiVenere reports no on page 22 for a more detailed discussion a financial relationships tr

s of different types of midwives in practice relevant to this article. today.) continued on page 22 illu

obgmanagement.com Vol. 24 No. 5 | May 2012 | OBG Management 21 Collaborative practice

Moving away from a physician- Who’s who in the midwifery world oriented system Like it or not, change is under way. Subtle Got acronym fatigue? Here’s a rundown of the various credentials and but important shifts are taking place in the certifying organizations. way maternity care is provided in your com- munity. The American College of Nurse-Midwives (ACNM) is a profes- The challenges facing our specialty? En- sional organization established in 1955 for certified nurse midwives and certified midwives. ACNM sets standards for academic prepa- suring that the highest levels of patient safety ration and clinical practice. For more information, visit http://www. and quality care are maintained. And edu- midwife.org. cating federal and state lawmakers, insurers, The American Midwifery Certification Board (AMCB) is the cer- and the public accordingly. tification organization affiliated with ACNM. This board was formerly called the ACNM Certification Council (ACC). Certification by AMCB Free-standing birth centers are is equivalent to certification by ACC. gaining prominence In 1997, AMCB opened its national certification exam to non- The Patient Protection and Affordable Care nurse graduates of midwifery education programs and issued the Act (ACA) establishes alternative pathways first certified midwife credential. Since 2010, a graduate degree has for maternity care. Congress, state lawmak- been required for entry into clinical practice for both certified nurse ers, and insurers want to know: Can access to midwives and certified midwives. http://www.amcbmidwife.org quality maternity care be provided at lower Certified midwife (CM). In 1996, the ACNM adopted standards for cost outside of hospitals or by nonphysi- the certification of direct-entry midwives. These midwives undergo cians? The answer isn’t clear. the same certification process as certified nurse midwives, but their training does not include education in nursing. CMs must pass the Under the ACA, free-standing birth cen- same certification exam as CNMs and must have a master’s degree. ters are a Medicaid maternity-care choice for CMs are licensed in only three states: New Jersey, New York, and low-income women. Birth centers appeal Rhode Island. New York had the first CM training program and was to lawmakers and insurers because of their the first state to recognize the CM credential. It is the only state that lower cost. For example, in 2008, the average has one unified framework for licensing all midwives—both CNMs facility cost for a vaginal delivery in a hospi- and CMs. tal, with no complications and no newborn Certified nurse midwife (CNM). A midwife who has training in both charges, was $8,920. In 2010, the average fa- nursing and midwifery. A master’s degree is required for certification. cility cost for a similar delivery at a birth cen- These midwives typically have prescriptive authority for most drugs; ter was $2,277.2,3 are eligible for third-party reimbursement, including Medicaid; and practice independently or in collaborative practice with physicians. We know that dollars alone don’t tell the full story—but they’re easy listening to law- Certified professional midwife (CPM). In the mid 1990s, the CPM makers’ ears. credential was developed jointly by the Midwives Alliance of North America (MANA), the North American Registry of Midwives (NARM), Since 2010, Medicaid payments are al- and the Midwifery Education Accreditation Council (MEAC). There lowed to go to state-licensed, free-standing is no single standard for education; both apprentice-only–trained birth centers even if they are not operated midwives and midwives who undergo university-affiliated training use by or under the supervision of a physician. the title CPM. Before the ACA became law, Medicaid paid A CPM can learn through a structured program, through appren- only for services provided in ambulatory ticeship, or through self-study. Another route to the credential is cur- centers under the supervision or oversight of rent legal recognition to practice in the United Kingdom. CPMs must pass a written and practical exam for certification. a physician. According to MANA, 24 states recognize the CPM credential as Another important change: Medic- the basis for licensure or use the NARM written exam. Some of these aid now reimburses for the services of any states use a different nomenclature. For example, licensed midwife provider who practices in a state-licensed, (LM) is used in California, Idaho, Oregon, and Washington; licensed free-standing birth center as long as that direct-entry midwife (LDM) is used in Utah; and registered midwife provider is practicing within the state’s scope (RM) is used in Colorado. of practice laws and regulations. That means SOURCE: ACOG10 that if a state allows doulas or lay midwives to provide childbirth care in free-standing

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birth centers, the federal and state Medicaid less highly trained providers. ACOG Presi- programs will pay for this care. This policy is dent Kenneth L. Noller, MD, MS, cautioned consistent with “any willing provider” rules them about the move, saying: “Even a nor- found elsewhere in Medicaid. mal pregnancy can become high-risk with There are 215 birth centers in the United little or no warning, and serious, sometimes States, with more in development. The num- life-threatening complications may arise for ber of birth centers has increased more than the woman and her fetus.” 20% over the past 5 years; they are regulated He noted that shoulder dystocia occurs in 41 states.4 in one in every 200 births and listed the fre- ACOG’s Guidelines for Perinatal Care quency of other complications: asserts: “The hospital, including a birthing • prolapsed umbilical cord: 1 in every center within a hospital complex, or free- 200 births standing birthing centers that meet the stan- • life-threatening maternal hemorrhage: dards of the Accreditation Association of 1 in 250 Birth Centers, provide the safest setting for • eclamptic seizures: 1 in 500 labor, delivery, and the postpartum period.”5 • uterine inversion: 1 in 700 • Apgar score of 0–3 at 5 minutes: 1 in 100 Reimbursements for nonphysicians to 200. are increasing Three years later, ACOG President Rich- Beginning in 2011, the Medicare program ard A. Waldman, MD, and American Col- began reimbursing CNMs, the most highly lege of Nurse Midwives (ACNM) President trained midwives, at 100% of the physician Holly Powell Kennedy, CNM, PhD, wrote: payment rate for obstetric services. Until “Collaborative practice [is] the provision of 2011, CNMs were paid at 65% of the physi- health care by an interdisciplinary team of cian’s rate for the same billed services. professionals who collaborate to accom- In addition, from 2011 through 2015, plish a common goal, and is associated with In 2011, Medicare CNMs whose primary care services account increased efficiency, improved clinical - out 5 began reimbursing for at least 60% of their Medicare-allowed comes, and enhanced provider satisfaction.” CNMs, the most charges will receive Medicare bonus pay- These messages demonstrate the impor- highly trained ments of 10%, reflecting Congress’ concern tance of careful use of collaboration to man- midwives, at 100% that our nation faces a serious shortage of age risk and maintain the highest standards of the physician primary care providers. of patient care. The questions for ObGyns Another important provision goes into who are considering collaborative practice: payment rate for effect in 2014: All health plans offered in a • What is careful use? obstetric services state insurance exchange must accept and • How do you collaborate carefully, without pay any provider recognized under state law increasing the risks faced by your patients for services covered by that plan. CPMs, some and your practice? of whom are among the least highly trained • How do you make collaboration a success? providers, are licensed to provide maternity ACOG has taken on these questions and of- care in 24 states. This provision may put pres- fers sound practical advice. sure on health insurers to pay for maternity care provided by CPMs, regardless of their training and certification, even if the insurer ACOG recommends high doesn’t contract with these providers. standards and clear practice agreements ObGyns have a long history of collabora- “Even a normal pregnancy can tion with our nurse-midwife colleagues— become high-risk” possibly one of the strongest collaborative In 2008, the Massachusetts legislature debat- traditions in medicine. ACOG supports the ed expanding childbirth care to encompass practice and licensure of trained midwives

24 OBG Management | May 2012 | Vol. 24 No. 5 obgmanagement.com credentialed by the ACNM. CNMs are A majority of CPMs lack well-educated, highly trained, and well- adequate training integrated into the health-care system. Few of the nation’s 1,400 CPMs in practice to- In addition to the ACNM standards, day meet the educational and training stan- ACOG supports the “global standards for dards accepted by ACOG and the ACNM. The midwifery education” established by the educational background of CPMs—known International Confederation of Midwives in some states as direct entry or lay mid- (ICM) in 2010: wives—varies widely across the nation. Un- • The minimum entry level of students is like CNMs, CPMs are not required to have a completion of secondary education nursing background. They practice primarily • The minimum length of a direct-entry in out-of-hospital settings, including birth- midwifery education program is 3 years ing centers and private homes. Many CPMs • The minimum length of a post-nursing/ have no formal academic education or medi- health-care provider program is 18 months cal training, and their training requirements • Standards are congruent with cur- fall short of internationally established stan- rent core ICM documents and position dards for midwives and traditional birth statements. attendants. ACOG strongly encourages that in Other relevant points: no case should the professional stan- • A person without a high school degree dards of any maternity provider be less could be licensed as a CPM if he or she than the standards established or ac- passed the certifying exam, observed cepted by ACOG or the ACNM. 20 deliveries, and participated as the pri- Effective collaboration depends on clear mary attendant in 10 practice agreements between physicians • As a group, CPMs have not adopted home- and CNMs, consistent use of shared prac- birth patient-selection criteria that are tice guidelines, and malpractice insurance based on generally accepted medical evi- coverage of all parties. A collaborative agree- dence or public safety Few of the nation’s ment that clearly spells out the mechanism • The curriculum, clinical skills training, 1,400 CPMs in for consultation, collaboration, and referral and experience of CPMs have not been practice today meet is essential to assure the best care. approved by the American Midwifery Cer- the educational and The picture gets a little trickier—and tification Board. Nor are they reviewed by training standards riskier—when we look at less-trained mater- the American Board of Obstetrics and Gy- accepted by ACOG nity providers. necology or the American Board of Family and the ACNM

Read more insightful articles by Lucia DiVenere!

›› How state budget crises are putting the squeeze on Medicaid (and you) (February 2012)

›› Is private ObGyn practice on its way out? with Janelle Yates (October 2011)

›› 14 questions (and answers) about health reform and you with Janelle Yates (June 2010)

Available in the archive at obgmanagement.com

obgmanagement.com Vol. 24 No. 5 | May 2012 | OBG Management 25 Collaborative practice

Medicine—recognized authorities in the for example, in a model from Washington certification of knowledge and skills asso- State: a high rate of vaginal delivery, low ciated with the practice of obstetrics. rate of cesarean birth, high rate of successful • The North American Registry of Midwives’ vaginal birth after cesarean (VBAC), and low Portfolio Evaluation Process requires mid- rate of repeat cesarean delivery.7 wives to be the primary care provider dur- ACOG’s policy on collaborative practice ing 50 home births and to have 3 years’ finds its origins just over 100 years ago in the experience. The average ObGyn resident Flexner report, quoted at the beginning of this gets this much experience in 1 month. article, which emphasized the need to ensure CPMs who lack a high school diploma that medical care in the United States is of no and are apprentice-trained only (with- less quality than in other parts of the world.1 out core curriculum training and formal Medical education and quality of care academic experience) clearly do not meet have improved dramatically over the past ACOG standards. Therefore, ACOG cautions century. ACOG is working to ensure the high- its Fellows and the public that, for quality est standards of care for pregnant women, and safety reasons, it “does not support the standards no lower than for the rest of the provision of care by ... midwives who are not population. certified by the American Midwifery Certifi- Collaboration is a time-honored tradi- cation Board” [ACNM’s accreditation body]. tion in ObGyn. Doing it right is key to patient Certification by this board, then, is a good in- safety. dication of skill. Acknowledgment The author acknowledges and thanks ACOG Requirements for successful Executive Vice President Hal C. Lawrence III, collaborative practice MD, for his helpful review and comments. Where can you look for examples of collabo-

Successful ration that work, and for data on the effects References collaboration of collaboration on health-care outcomes? 1. Flexner A. Medical Education in the United States and Four articles in the September 2011 issue of Canada. A Report to the Carnegie Foundation for the between ObGyns Advancement of Teaching. Bulletin No. 4. 1910. Boston, and certified Obstetrics and Gynecology highlight success- Mass: D. B. Updike, Merrymount Press; 1972. ful models of collaboration between ObGyns 2. American Association of Birth Centers. Uniform Data Set. nurse midwives 2010 Data. Perkiomenville, Pa: ASBC; 2011. can improve job and CNMs in very different, well-established 3. Facts and Figures 2008. Healthcare Cost and Utilization maternity programs.6–9 In each article, the Project (HCUP). October 2010. Agency for Healthcare satisfaction and Research and Quality, Rockville, MD. www.hcup-us.ahrq. authors describe their ­collaborative practice health outcomes gov/reports/factsandfigures/2008/TOC_2008.jsp. Accessed model in some detail, offering guidance to March 30, 2012. others interested in successful collabora- 4. American Association of Birth Centers. http://www. birthcenters.org. Accessed March 30, 2012. tion. Common threads run through these 5. Waldman RN, Kennedy HP. Collaborative practice narratives: between obstetricians and midwives. Obstet Gynecol. 2011;118(3):503–504. • trust 6. Shaw-Battista J, Fineberg A, Boehler B, Skubic B, Woolley • communication D, Tilton Z. Obstetrician and nurse-midwife collaboration: successful public health and private practice partnership. • mutual respect Obstet Gynecol. 2011;118(3):663–672. • administrative support for continuing 7. Darlington A, McBroom K, Warwick S. A Northwest collaborative practice model. Obstet Gynecol. medical education 2011;118(3):673–677. • consensus meetings 8. Hutchison MS, Ennis L, Shaw-Battista J, et al. Great minds don’t think alike: collaborative maternity care • common adherence to accepted guidelines at San Francisco General Hospital. Obstet Gynecol. • an established support network for back- 2011;118(3):678–682. 9. DeJoy S, Burkman RT, Graves BW, et al. Making it work: up and transfer. successful collaborative practice. Obstet Gynecol. The benefits to ObGyns include greater 2011;118(3):683–686. 10. American Congress of Obstetricians and Gynecologists. job satisfaction. Benefits to patients include Glossary of Midwifery Organizations and Terms. Washington, improved health outcomes, as demonstrated, DC; 2010.

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