Midwife Collaborations Continue to Evolve

September 26, 2013

• Leading experts discuss the emergence of certified nurse midwives into mainstream obstetric care. • Has your practice implemented collaborative care practices?

As collaborations between certified nurse midwives and physicians continue to grow, professional groups for both are working to outline best practices for meeting the health care needs of women.

“I don’t think you’ll find one size fits all,” said Jeanne Conry, MD, president of the American Congress of Obstetricians and Gynecologists (ACOG). “It truly is an evolutionary process. But you will see more practices shift to where physicians are looking at how to achieve balance in their practices.”

While many practices have had long-standing collaborations with nurse midwives, the use of midlevel practitioners, nurse midwives in particular, is expected to continue to grow, she said.

The prevalence of nurse midwives in private practices, labor and delivery rooms, and clinics suggests that women are becoming accustomed to a visit that doesn’t always mean seeing a physician, said Ginger Breedlove, PhD, CNM, APRN, FACNM, president of American of College of Nurse-Midwives (ACNM).

The shift can be seen in a number of ways, one of them being the steady increase in the rate of midwife-attended births, which has grown nearly every year since 1989, when the data was first made available. This shift is also apparent in individual hospitals, where more midwives are occupying hospital labor and delivery floors, and in private practices, where more patients are asking to see a midwife.

“There is a shift in awareness that the ob/gyn world sees a value in our role,” Breedlove said. “We’re approaching the 60th anniversary of our professional association-we’ve been around a long time-and we’re getting closer to a tipping mass. It’s hard to ignore the fact that there is a master-level professional provider who excels in caring for normal-health women.”

However, there are still unknowns and irregularities in how certified nurse midwives and physicians can best collaborate. With that in mind, the ACNM board voted this month to form a task force on how to best approach their colleagues at ACOG about jointly creating a tool kit to outline the best practices for collaboration, Breedlove said. The tool kit would cover working together in any number of settings from labor and delivery hospital wings to federally qualified health centers and rural and urban private practices, she said.

“We need templates for how collaborations in different settings work,” she said. “It’s really urgent that we begin to put this together in a way that can be easily transferred into someone needing help establishing a collaborative practice and wanting to move in this direction.”

This is by far the first of such efforts to better define and outline the future roles within an increasingly collaborative environment. Researchers are seeking better ways to measure how patient outcomes and satisfaction rates are influenced by midwifery care. Elsewhere, insurance billing rates, malpractice liability, and the process of gaining hospital privileges can still vary wildly by region, prompting some to call for more uniformity where possible.

“Where midwives can get privileges, what they can do, and how they function is still evolving,” said Lani Pincus, CNM, MS, NP, who works with two physicians and one other certified nurse midwife at Mid Hudson Medical Group in New York. “Some hospitals are more restrictive. It usually takes one person to break that mold to where other physicians see that this could be a standard.”

Helping to break that mold in regions where midwifery is scarce is part of what Breedlove hopes a tool kit could provide. “There is still a lot of confusion and fear,” Breedlove said. “But there are answers … And taking that collective knowledge, experience, and success and putting it in a way that doesn’t make it seem so daunting reduces that fear.”

In addition to ACNM’s still nascent attempt to create a tool kit, others are already seeking to collectively build cohesive plans for clinical care. For example, physicians of different specialties and midlevel providers are working together to identify the elements that should always be part of a well-woman visit irrespective of the credential of the provider seeing the patient, Conry said.

The process includes bringing together representatives from internal medicine, family practice, pediatrics, as well as midlevel providers such as certified nurse midwives, nurse practitioners, and physician assistants. The goal is to have those elements identified by next year, Conry said.

“You’ve got to have those kinds of things as a baseline or focus for all of us,” Conry said. The effort is propelled in part because the Affordable Care Act required insurance companies to cover in full annual well-woman visits and many preventive tests, such as mammograms. It also comes amidst a national push for more team-based approaches to medicine and a specific need for ob/gyns to address looming physician shortages.

For those certified nurse midwives on the ground, the evolution of their work is obvious. However, there are still some growing pains to be had and lessons to be learned.

“I think we are just feeling more solid in how we work together,” said Abbe Kirsch, CNM, assistant director of midwifery service at Bronx-Lebanon Hospital Center in New York. “I don’t think there will be an ‘ah-ha’ moment. But we are finding our way, and we’re still constantly trying to improve.”

Time has made a difference, Kirsch said, noting that the number of certified nurse midwives employed by the hospital grew from 2 a decade and a half ago to 22 today.

While the numbers may be a blatant reminder of the economic reality that certified nurse midwives are less expensive than physicians, other subtle changes also show the progress. One such change occurred 2 years ago, when midwives began covering the labor and delivery floor 24 hours a day, Kirsch said.

“I think this is really about taking advantage of what everyone’s specialty is,” commented Kirsch. “We absolutely need physicians. We can’t deal with operative deliveries and complications, and there are always going to be people who need that. But letting the midwives take care of normal-health women shapes the patient experience. It is not about dealing with the problem; it’s dealing with the person. That’s what we do.”