Certified Nurse-Midwives: Changing Health Care for the Better

1. Certified Nurse-Midwives: Changing Health Care for the Better Leona VandeVusse, PhD, RN, CNM, FACNM 10-13-10 [with embedded quiz questions]

2. Midwives are which of the following? • Historic community healers, often women, largely eliminated during witch-hunts • The exemplary care providers observed by Semmelweis when he formulated the germ theory • A group often restricted by class, race, & gender biases D. A relatively new phenomenon

3. Midwifery:An Ancient Commitment,A Modern Success Story

4. ‘Midwife’ Defined Literal Definition: "with woman" Traditionally: • Older experienced female in family or community • Often apprentice-trained Today, CNMs [since 1925 in USA]: • Highly educated professionals • Work collaboratively with physicians CNMs provide primary care beyond labor & birth: • Focus on women’s specific needs • Offer a variety of options • Minimize unnecessary intervention

5. CNMs Do More than Birth Care! Scope of Nurse-Midwifery Practice: • Pregnancy, birth, & newborn care • Women’s primary care & health promotion • Family planning • Advanced clinical practice by some, e.g. • first assist in surgery • circumcision • colposcopy • ultrasonography • Education • Public Health

6. Labor & Birth Primary Care Non-Maternity Emphasis on Primary Care Primary Care During Pregnancy American College of Nurse-midwives. Nurse-Midwives: Quality care for women and newborns. Washington, D.C.: American College of Nurse-Midwives; 1999.

7. Differences between WI CNMs & LMs Both are recognized by WI statutes & certified by their respective organizations

8. CNM Advantages Meet requirements: • graduate from a nationally accredited education program with master’s degree or higher • pass a rigorous national certification exam • are licensed to practice, including Advanced Practice Nurse Prescriber eligibility • carry mandated professional liability Ensure comprehensive care through collaboration with others Use formal mechanisms to maintain continued competency Continuous improvement with peer review

9. American College of Nurse-Midwives (ACNM) Sets National Standards for Practice Standards for the Practice of Midwifery Core Competencies for Basic Midwifery Practice Peer review Code of Ethics Clinical Bulletins Documents available online at www.midwife.org

10. ACNM Program Institutional Coverage Private Carriers CNMs Have Availability of Professional Liability Insurance CNM CM [not recognized in WI]

11. Where CNMs practice? Where CNMs attend most births? • Birth Center • Hospital • Home • Outpatient offices • Community

12. Location of CNM-attended births % • Planned Home Birth: Another Safe Option with CNMs • Low Infant Mortality 2.5 per 1000 • Transfer to hospital during labor 8.3% • Postpartum/Neonatal Transfers 1.9%

13. CNMs’ Philosophy of Care • Focus on prevention & education • View pregnancy & other life transitions such as menopause as normal processes • Provide compassionate, family-centered care • Encourage women’s participation in decision-making • Use technology & intervention appropriately Available from: www.midwife.org

14. Areas where CNMs have led providers in applying EBP? • Food & drink during labor, not NPO • Intermittent fetal monitoring • Positions other than lithotomy for birth • Support of spontaneous pushing • Non-routine, indicated episiotomy

15. CNMs Provide Effective Labor Support • Twice as much ambulation in labor • Twice as much intermittent monitoring • Twice as many unmedicated births • Half as many episiotomies • Supportive care during labor

16. CNMs Use Technology & Birth Interventions Appropriately Percent Rosenblatt RA, et al. Interspecialty differences in the obstetric care of low-risk women. American Journal of Public Health 1997;387:344-51.

17. Unique Points about CNM Practice Offer: • Family involvement • Continuous labor support • Alternative hours to accommodate needs Additional innovative options: • Group Prenatal Care • Hydrotherapy or Waterbirth

18. CNMs Serve a Wide Variety of Women Our clientele are: • 7.5% of all births • 10% of vaginal births • 50% women of color • 16% uninsured • 27% immigrants • 29% teenagers About 70% of clients are ‘vulnerable’ Declercq ER, et al. Serving women in need: nurse-midwifery practice in the United States. JMWH 2001;46(1):11-6.

19. Midwifery Prenatal Care (PNC) Contributes to Excellent Outcomes Group PNC (e.g., CenteringPregnancy® ) was shown to be effective, with a significant reduction in prematurity, compared to those who received traditional prenatal care in the following: Ickovics JR et al. Group prenatal care & preterm birth weight: results from a matched cohort study at public clinics. Obstet Gynecol 2003;102(5 Pt 1):1051-7.

20. CNMs Have Excellent Outcomes MacDorman MF, Singh GK. Midwifery care, social and medical risk factors, and birth outcomes in the USA. Journal of Epidemiology and Community Health 1998; 52:310-7.

21. Comparative research in USA on CNMs & physicians? • Is not actually possible due to disciplinary differences B. Is a new phenomenon C. Has continued to find similar results over decades

22. Before, During, & After CNM Care: A Classic Study

23. Nurse-midwives’ quality of care compared to physicians? • Better on a variety of clinical parameters • More cost-effective • Always equivalent • Consistently inferior as non- physicians See ACNM’s QuickInfo on ‘Quality & Effectiveness of Nurse-Midwifery Practice’. See ACNM’s QuickInfo on ‘Cost Effectiveness’ . Jacox A. The OTA report: a policy analysis. Nursing Outlook 1987;35:262-7.

24. Patients Prefer Practices with CNM Providers Oakley D et al. Comparisons of outcomes of maternity care by obstetricians and certified nurse-midwives. Obstetrics and Gynecology 1996;88:823-9. Bell KE, &Mills JI. Certified nurse-midwife effectiveness in the health maintenance organization obstetrics team. Obstetrics and Gynecology 1989;74:112-6.

25. How do CNMs work with other providers? • They report only to their supervising physicians • They collaborate, consult, & refer appropriately with a variety of providers as needed for client care • They don’t collaborate, because they are ‘independent’ providers

26. Collaborative Practice with Physicians • Consultation • Co-Management • Referral MD/DO Jackson et al. Outcomes, safety, and resource utilization in a collaborative care birth center program compared with traditional physician-based perinatal care. American J of Public Health 2003;93(6), 999-1006.

27. Interpretations of Physician Collaboration with CNMs? • Control of CNM practice • Direct supervision • Vicarious liability • Payment required for availability & consultation • Partners in providing best care for each woman

28. Collaboration Clarified • Potential to optimize individualized care of every women • Important in clinical area for all professionals • Unfortunately has been used to create barriers to CNM practice: • restraint of trade’ issue • finding loophole language to continue to ‘supervise’, e.g., Patient Compensation Fund • An area needing legislative attention

29. The CNM group is what size, compared to the types of APNs [NPs, CNMs, CRNAs, CNSs]? • The largest • A mid-range size • The smallest

30. Political Power • Leverage our relationship with nursing & APNs [recent IOM paper] • Find ways to counteract powerful lobbying against APNs that AMA does • Work with allies [Leg. Council Committee] • Connect with other interested & supportive groups who want optimal health care for women & families [ACOG] • Other ideas??

31. CNM Hospital Practice Privileges • JCAHO permits & does not restrict • Delivery and Admitting privileges possible, related to: • CNM’s experience, responsibility & accountability commensurate with role (admission, care, and discharge) • Type of facility • Consultant relationship • Credentialed as a category of Medical Staff • Change is often slow • ACNM has helpfulexamples of ‘bylaws’ • Several WI hospitals have (intermittently) credentialed CNMs as full Medical Staff members Williams DR. Credentialing certified nurse-midwives. Journal of Nurse-Midwifery 1994;39:258-64. Williams DR, Keleher K. The JCAHO medical staff standards: impact on clinical privileges for nurse-midwives. Journal of Nurse-Midwifery 1996; 41:43-6.

32. Percent of CNM Attended Births

33. Growth of Nurse-Midwives in WI

34. In summary, CNMs are ‘Changing Health Care for the Better’ • A modern success story built on an ancient commitment • Maternity, gynecological, well woman care • Emphasis on primary care & health promotion • The midwifery model: high-touch, low-tech • Excellent outcomes, satisfied patients, & value-added service • Quality, accessible, cost-effective professional care

35. Suggested Legislative Actions • Remove requirement for formal agreement with physician(s) • Alter language used publicly & in statute, e.g., "health care provider” • Promote APN/CNM access to hospital admission privileges • Include CNMs in Pt Compensation Fund for reasonable (affordable) fee • Develop & fund demonstration projects to allow CNMs to serve under-served population & monitor outcomes, e.g., instituting 'health' "homes" • Actively support establishment of freestanding birth centers in WI • Designate funding to support & increase access to nurse-midwifery education • Institute additional fellowships, scholarships, loan reimbursement, &/or tax credits to reward nurses for graduate nursing, especially doctoral, degrees to increase faculty • Increase support to allow graduate nursing programs to improve faculty recruitment 10. Possibly reimburse CNM preceptors to increase clinical site availability

36. Acknowledgement Adaptedfrom an American College of Nurse-Midwives’ presentation Contact:leona.vandevusse@mu.edu Office:  414-288-3844,     Fax:  414-288-1939 Associate Professor & Nurse-Midwifery Program Director Marquette University College of Nursing P.O. Box 1881, Milwaukee, WI  53201-1881