Nurse midwives

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Certified Nurse-Midwives:Changing Health Care for

the Better Leona VandeVusse, PhD, RN, CNM, FACNM

10-13-10[with embedded quiz questions]

Midwives are which of the following?

A. Historic community healers, often women, largely eliminated during witch-hunts

B. The exemplary care providers observed by Semmelweis when he formulated the germ theory

C. A group often restricted by class, race, & gender biasesD. A relatively new phenomenon

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Midwifery:An Ancient Commitment,A Modern Success Story

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‘Midwife’ DefinedLiteral 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 physiciansCNMs provide primary care beyond labor & birth:• Focus on women’s specific needs • Offer a variety of options• Minimize unnecessary intervention

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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

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Emphasis on Primary Care

Primary Care During Pregnancy

Labor & BirthPrimary CareNon-Maternity

American College of Nurse-midwives. Nurse-Midwives: Quality care for women and newborns. Washington, D.C.: American College of Nurse-Midwives; 1999.

Differences between WI CNMs & LMsCNMs LMs

Formally educated Yes Not necessarilyScope of practice Primary care of ♀

across life spanChildbearing cycle

Prescriptive practice

Yes, as APNP Several meds allowed

Place of birth All settings Out-of-hospital onlyCollaboration required

Yes No

Malpractice coverage

Yes No

7Both are recognized by WI statutes & certified by their respective organizations

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CNM AdvantagesMeet 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 othersUse formal mechanisms to maintain continued competencyContinuous improvement with peer review

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American College of Nurse-Midwives (ACNM) Sets National Standards for Practice

Standards for the Practice of MidwiferyCore Competencies for Basic Midwifery PracticePeer reviewCode of EthicsClinical Bulletins

Documents available online at www.midwife.org

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CNMs Have Availability of Professional Liability Insurance

CNMCM [not recognized in WI]

ACNM Program

Institutional Coverage Private Carriers

Where CNMs practice? Where CNMs attend most births?

A.Birth CenterB.HospitalC.HomeD.Outpatient officesE.Community

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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%

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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

appropriatelyAvailable from: www.midwife.org

Areas where CNMs have led providers in applying EBP?

A. Food & drink during labor, not NPOB. Intermittent fetal monitoringC.Positions other than lithotomy for birthD.Support of spontaneous pushingE. Non-routine, indicated episiotomy

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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

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CNMs Use Technology & Birth Interventions Appropriately

PercentRosenblatt RA, et al. Interspecialty differences in the obstetric care of low-risk women. American Journal of Public Health 1997;387:344-51.

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Unique Points about CNM Practice

Offer:• Family involvement• Continuous labor support• Alternative hours to accommodate needsAdditional innovative options: • Group Prenatal Care• Hydrotherapy or Waterbirth

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CNMs Serve a Wide Variety of Women Our clientele are:

7.5% of all births10% of vaginal births50% women of color16% uninsured27% immigrants29% 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.

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Midwifery Prenatal Care (PNC) Contributes to Excellent Outcomes

Lifestyle Advice Em otional Support Pregnancyand BirthEducation

Laboratory Testsand

M edicalInterventions

M idw iferyPrenatal

Care

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.

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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.

Comparative research in USA on CNMs & physicians?

A. Is not actually possible due to disciplinary differences B. Is a new phenomenonC. Has continued to find similar results over decades

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

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Nurse-midwives’ quality of care compared to physicians?

A. Better on a variety of clinical parametersB. More cost-effectiveC. Always equivalentD. Consistently inferior as non- physicians

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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.

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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.

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

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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.

Interpretations of Physician Collaboration with CNMs?

A. Control of CNM practiceB. Direct supervision C. Vicarious liabilityD. Payment required for availability &

consultationE. Partners in providing best care for

each woman27

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

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The CNM group is what size, compared to the types of APNs

[NPs, CNMs, CRNAs, CNSs]?

A. The largestB. A mid-range sizeC. The smallest

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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??30

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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 helpful examples of ‘bylaws’ Several WI hospitals have (intermittently) credentialed

CNMs as full Medical Staff membersWilliams 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.

Percent of CNM Attended Births

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Growth of Nurse-Midwives in WI

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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

Suggested Legislative Actions1. Remove requirement for formal agreement with physician(s)2. Alter language used publicly & in statute, e.g., "health care provider”3. Promote APN/CNM access to hospital admission privileges4. Include CNMs in Pt Compensation Fund for reasonable (affordable) fee 5. Develop & fund demonstration projects to allow CNMs to serve under-

served population & monitor outcomes, e.g., instituting 'health' "homes" 6. Actively support establishment of freestanding birth centers in WI7. Designate funding to support & increase access to nurse-midwifery education8. Institute additional fellowships, scholarships, loan reimbursement, &/or tax

credits to reward nurses for graduate nursing, especially doctoral, degrees to increase faculty

9. Increase support to allow graduate nursing programs to improve faculty recruitment

10. Possibly reimburse CNM preceptors to increase clinical site availability

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Acknowledgement

Adapted from an American College of Nurse-Midwives’ presentation

Contact: leona.vandevusse@mu.eduOffice:  414-288-3844,     Fax:  414-288-1939

Associate Professor & Nurse-Midwifery Program DirectorMarquette University College of NursingP.O. Box 1881, Milwaukee, WI  53201-1881

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