More and more OB/GYNs are eliminating obstetric care from their practice. So who will deliver all the babies if not for midwives?
The United States is facing an OB/GYN crisis. According to the 2012 American College of Obstetricians and Gynecologists (ACOG) survey of over 9000 OB/GYNs, some practices have made changes to their obstetric offerings since the last survey in 2009. About 8% of OB/GYNs are delivering fewer babies, and 5% of OB/GYNs have stopped offering any obstetric care. This could result in an overburdened health care system for pregnant women, especially in already underserved areas. Certified Nurse Midwives (CNMs) can help fill this gap in the availability of prenatal care services, whether women choose to deliver their babies at home, in a birthing center, or in the hospital.
To clarify the differences in midwife credentials and how they translate into practice, Elaine Germano, CNM, DrPH, FACNM, of the American College
of Nurse-Midwives has written an associated Commentary, where she more accurately explains the licensing distinctions and how these differences may affect collaboration efforts.
However, CNMs may find themselves unable to practice in some areas because of the need for them to forge a partnership with a local OB/GYN. A midwife and her patients in Watertown, NY, a small city 70 miles north of Syracuse, is in just such a predicament. The collaborative physician is closing his practice and moving to practice on the local military base, where his services will only be available to military families. Another local OB/GYN has decided to discontinue obstetric services. Without an agreement with an OB/GYN, Joyce Wilder, CNM, WHNP may also need to close her practice, Wilder’s Women’s Healthcare. Current patients, including those who might soon deliver, would need to seek alternative care. "These women will be forced to see someone they don’t want to see," she told the Watertown Daily Times. What's happening in Watertown is reflected in the 2012 ACOG survey of OB/GYNs - in New York about 12% of OB/GYNs are delivering fewer babies and about 10% are no longer providing obstetric services.
Maternal care practitioners' opinions on collaboration span the entire spectrum: from seeing no benefit in partnerships, to entering partnerships only because of local laws, to believing that a CNM/OB team is in everyone's best interest. At the heart of the issue is the vast difference in how midwifery is practiced and licensed throughout the United States. In some states, Certified Professional Midwives (CPMs) can practice, while in others, certain licensing requirements must be met. Licensing for midwives is not offered in all states. In 12 states, midwives must enter into a collaboration with a physician: 6 require a written agreement and 6 require that midwives must be supervised by a physician. Collaboration isn't exactly what it sounds like, however. Even a supervisory agreement doesn't mean that the midwife has to share a practice space with the physician - collaborating practitioners could be in different parts of the same state.
Another hurdle that collaboration brings is the question of malpractice insurance. Midwives can, and do, carry their own malpractice insurance, but having a midwife collaboration could increase malpractice insurance for physicians. Among physicians, OB/GYNs have some of the highest malpractice insurance rates. High malpractice rates is the reason that some practitioners cite for their decision to stop seeing pregnant patients and delivering babies, or to only provide prenatal care in the early stages of pregnancy.
The official policy from the American College of Nurse Midwives (ACNM) is that requiring signed collaborative agreements between midwives and physicians implies that midwives need supervision, doesn't guarantee communication, and creates an "unfair economic disadvantage for CNMs/CMs." However, the Best Practice Guidelines from the Home Birth Summit includes a statement that "collaboration within an integrated maternity care system is essential for optimal mother-baby outcomes." While regulated collaboration may not provide caregivers with their chosen practice environment, voluntary collaboration may be the future of maternity care. The health care space is changing: fewer OB/GYNs are available and pregnant women need care from a qualified practitioner. The authors of one study of collaboration in Washington State wrote that "well-defined and communicated" roles for care providers resulted in higher rates of vaginal delivery and lower rates of c-sections. Another review study acknowledges that the changing maternal care environment might be best addressed with interprofessional collaboration.
Pregnant women need, and should be entitled to, qualified, efficient care from their providers. The environment in health care is evolving, not just in obstetrics, but in many specialties of care, and so are the needs and wants of patients. The shortfall of OB/GYNs in the United States presents both a challenge and an opportunity for providers to develop and institute a process of collaboration that can not only provide patient-centered care, but also improve job satisfaction for practitioners.
2012 ACOG Survey on Professional Liability Results
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2012 ACOG Survey on Professional Liability Results. National Summary. ACOG.org. 2012.
American College of Nurse Midwives (ACNM). Collaborative Agreement between Physicians and Certified Nurse-Midwives and Certified Midwives. December 2011.
Darlington A, McBroom K, Warwick S. A northwest collaborative practice model. Obstet Gynecol. 2011 Sep;118(3):673-7. doi: 10.1097/AOG.0b013e31822ac37f. Available at: http://www.ncbi.nlm.nih.gov/pubmed/21860299.
Home Birth Summit. Best Practice Guidelines: Transfer from Planned Home Birth to Hospital. 2013. Available at: http://www.homebirthsummit.org/wp-content/uploads/2014/03/HomeBirthSummit_BestPracticeTransferGuidelines.pdf.
Madden R. Midwife Joyce Wilder closing practice unless physician agreement is made. 2 Oct 2014. Available at: http://www.watertowndailytimes.com/article/20141001/NEWS03/141009823.
New York State Education Department. Midwifery - Questions & Answers. April 7, 2014. Available at: http://www.op.nysed.gov/prof/midwife/midwifeqa.htm.
Stevens JR, Witmer TL, Grant RL, Cammarano DJ 3rd. Description of a successful collaborative birth center practice among midwives and an obstetrician. Obstet Gynecol Clin North Am. 2012 Sep;39(3):347-57. doi: 10.1016/j.ogc.2012.05.003. Epub 2012 Aug 11. Available at: http://www.ncbi.nlm.nih.gov/pubmed/22963694.