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Nurse-Midwives in Georgia: Value for Georgia Citizens
Nicole S. Carlson PhD, CNM
President, Georgia Affiliate of
American College of Nurse-Midwives
Assistant Professor
Emory University School of Nursing
Birth in Georgia
Georgia Births in 2013: 128,748
One of nation’s highest Women in GA at
increased risk for:
• Maternal Pregnancy-Related Mortality
• Infant Mortality • Premature
delivery • Cesarean
delivery
Kaiser Family Foundation, 2015
Maternity Care Workforce
Current Maternity Care Providers in the US
OB/GYNs
• Medical degree & specialized residency
• Skilled in specialized surgical techniques and primary care
• Trained to attend low, moderate and high risk births and address complications and co-morbidities
• 99.9% of births they attend occur in hospitals.
Certified Nurse Midwife
• Masters Degree
• Skilled in normal birth for women with low-moderate risk
• Provide primary care to women of all ages
• 94.6% of the births they attend occur in hospitals.
Certified Professional
Midwife • Most complete a non-
accredited apprenticeship model of education
• Care for women of low risk
• Do NOT provide primary care
• 16.9% of births they attend occur in hospitals
Ideal Maternity Care Workforce Structure
Current US Workforce Structure
0
5,000
10,000
15,000
20,000
25,000
30,000
35,000
40,000
45,000
43,732
11,113 1,800
Nu
mb
er
of
Pro
vid
ers
OB/GYNs CNMs/CMs CPMs
Physicians are the most common maternity care provider in the US.
Sources in Notes View.
Percent of 2013 U.S. Births Physicians: 90.4% Nurse-Midwives: 8.2% Other Midwife: 0.7%
Inter-Professional Collaboration – The Ideal
Lower
Risk Patients
Moderate Risk
Patients
Higher Risk
Patients
Midwife-Led Care
Physician-Led Care
Jointly-Led Care
“Ob-gyns and CNMs/CMs are experts in their respective fields of practice and are educated, trained, and licensed, independent providers who may collaborate with each other based on the needs of their patients. Quality of care is enhanced by collegial relationships characterized by mutual respect and trust, as well as professional responsibility and accountability.” Joint Statement of Practice Relations Between Obstetrician/Gynecologists and Certified Nurse-Midwives/Certified Midwives
Sources in Notes View.
Percent of Births Attended by CNMs - 2013
MT
9.70%
WY
4.48%
ID
7.83%
WA
9.32%
OR
17.81%
NV
3.96% UT
8.04% CA
8.72%
AZ
6.51%
ND
6.13%
SD
6.73%
NE
5.88%
CO
12.47%
NM
24.95%
TX
3.16%
OK
4.04%
KS
4.94%
AR
0.56%
LA
2.62%
MO
3.31%
IA
7.33%
MN
10.99% WI
9.12%
IL
6.24%
IN
6.38%
KY
5.95%
TN 5.72%
MS
2.28%
AL
1.67% GA
14.02%
FL
10.41%
SC
4.30%
NC
12.59%
VA
7.22%
WV
12.37%
OH
6.80%
MI
6.53%
NY
10.12%
PA
11.41%
MD 9.74%
DE 8.77%
NJ 6.90%
CT 11.01%
RI 11.13%
MA 15.22%
ME
17.78% VT 20.87%
NH 18.95%
AK
26.80%
HI 8.81%
4.51% – 6.49% of births
6.50% - 8.89% of births
12.00% - 28.00% of births
Source: CDC Vital Stats, Births - Available at: http://www.cdc.gov/nchs/data_access/vitalstats/vitalstats_births.htm
8.90% - 11.99% of births
0% – 4.50% of births
DC 10.72%
Obstetricians by GA County
48% of GA counties do not have an obstetrician
Of those counties with any obstetrician, 22% have only one
Certified Nurse-Midwives by GA County
53% of GA counties do not have a Certified-Nurse Midwife
Of those counties that do have Certified Nurse-Midwife presence, 31% have only one
501 CNMs currently
licensed in GA
(Nov, 2015)
South Georgia Sparcity of CNMs
OB-GYNs in Georgia
CNMs in Georgia
Where do GA CNMs work? Place of Employment Number of GA CNMs
Hospital 173
Ambulatory clinic 69
Public Health 8
Insurance claims/benefits 2
Nursing Home/Extended Care 2
Home Health 9
Academic 33
Correctional facility 1
School health service 2
Other 68
Community health 16
TOTAL 383
Source: GA APRN Leadership Taskforce Survey, 2015
32% of CNM licensed in GA do not provide prenatal or
birth care.
Where do GA CNMs work? Place of Employment Number of GA CNMs
Hospital 173
Ambulatory clinic 69
Public Health 8
Insurance claims/benefits 2
Nursing Home/Extended Care 2
Home Health 9
Academic 33
Correctional facility 1
School health service 2
Other 68
Community health 16
TOTAL 383
Source: GA APRN Leadership Taskforce Survey, 2015
Reasons cited by CNMs for not providing midwifery
care: •Difficulty finding jobs
•Difficulty finding physician collaborators
•Difficulty getting hospital privileges
Many student CNMs educated in GA leave the
state for the same reasons.
Savings in Care by Certified Nurse Midwives
Average Total Charges and Payments for Maternal and Newborn Care in the U.S. - 2010
$0
$10,000
$20,000
$30,000
$40,000
$50,000
$60,000
Commercial -Vaginal
Commercial -Cesarean
Medicaid -Vaginal
Medicaid -Cesarean
$3
2,0
93
$5
1,1
25
$2
9,8
00
$5
0,3
73
$1
8,3
29
$2
7,8
66
$9
,13
1
$1
3,5
90
Charges
Sources in Notes View.
The gap between costs and reimbursement puts great strain on healthcare systems Cesarean birth results in larger financial losses for the hospital and providers, especially for Medicaid patients
Savings From the Midwifery Model – Cesarean Sections
Hypothetical Group of 1,000 Women
Number of Women Giving Birth via
Cesarean Section
Payments for All 1,000 Births if All Covered by
Medicaid
Payments for All 1,000 Births if All Covered by
Commercial
CNM Attended Women
(8.5% cesarean rate)
85 $9,837,106 $19,797,863
Physician Attended Women
(14.7% cesarean rate)
147 $10,122,014 $20,407,230
Reduced Cesareans/Savings
from Midwifery Model
62 $284,908 $609,367
Description of methodology in “Notes” view.
What Can Policymakers Do to Access Savings through the Midwifery Model?
Regulatory Structure for Certified Nurse-Midwives and Certified Midwives
Data Current as of June 2014
MT
WY
ID
WA
OR
NV
UT
CA
AZ
ND
SD
NE
CO
NM
TX
OK
KS
AR
LA
MO
IA
MN
WI
IL IN
KY
TN
MS AL GA
FL
SC
NC
VA WV
OH
MI
NY
PA
MD
DE
NJ
CT RI
MA
ME
VT
NH
AK HI
DC
Supervision Required
Written Collaborative Agreement
Written Collaborative Agreement --- Rx Only
Independent Practice
Source: ACNM analysis of state laws and regulations.
Legally required supervisory or collaborative business relationships are not the same thing as normal collegial provider relationships that result in consultation, collaboration and referral. Inability to find a physician who will enter into such a business relationship often limits where midwives can practice and what they can do.
Full Practice Authority
Medical Staff Provisions for Certified Nurse-Midwives in Law and Rule
Data Current as of January 2014
MT
WY
ID
WA
OR
NV
UT
CA
AZ
ND
SD
NE
CO
NM
TX
OK
KS
AR
LA
MO
IA
MN
WI
IL IN
KY
TN
MS AL GA
FL
SC
NC
VA WV
OH
MI
NY
PA
MD
DE
NJ
CT RI
MA
ME
VT
NH
AK HI
DC
Membership is Denied Note: Could be Implicit or Explicit Denial
Membership is Allowed Note: Could be Implicit or Explicit Allowance
Source: ACNM analysis of state laws and regulations.
Nearly 95% of CNM attended births occur in a hospital. Hospitals are often allowed, but not required to extend staff membership to CNMs on the same footing as they do physicians. Not being on staff means they can’t help formulate or vote on policies that directly impact their ability to uphold the midwifery model.
Hospital Privileges and Medical Staff Participation
Athens Regional Medical Center Midwives
• Practice started 1976 to provide accessible, high-quality care and delivery for women using Medicaid in Athens/Clarke county.
• Now: CNMs at ARMC travel to Greene, Barrow, and Banks counties every week to provide prenatal care.
• Plans to expand model to Morgan and Elbert counties
• Women come to Athens Regional: – for labor with a CNM – For ultrasounds – For high-risk consultation or
cesarean with physician
Support Midwifery/Physician Collaboration
Athens Regional Midwifery Service
Claude Burnett, MD, MPH, Director of the North East GA Health District: “The infant mortality rate in the Athens District has steadily declined over the past 30 years, partially due to the services and standard of care provided by the Athens Regional Nurse-Midwifery Practice.
Preterm Birth Rate
Infant Mortality
Clarke County 13% 6/1,000 live births
Athens Regional Midwifery Service
6-7%
3/1,000 live births
Nurse-Midwives from rural county clinics rotate to provide normal Labor &
Delivery Care
Physician Hospitalist provides:
•Cesarean delivery •Consultation with midwives •Higher-risk antepartum visits •Ultrasounds
Nurse-Midwives care for women within counties
Perinatologist at Regional Medical Center provides:
•High-risk consultation (tele-health, in person) •Antepartum hospitalization
Georgia Rural Maternity Care Model
Next Steps for Georgia to Increase Use of Nurse-Midwives
Support Midwifery/Physician Collaboration
Full Practice Authority
Hospital Privileges and Medical Staff Participation
Fund Education of Nurse-
Midwives in GA
• Ensure that applicable laws and regulations allow CNMs to freely utilize the full extent of their education and training.
• Ensure that hospitals provide CNMs with privileges and include them on medical staff.
• Expand GA’s Preceptor Tax Incentive Program to cover Nurse-midwife preceptors
• Expansion of GA’s Rural Physician Tax Credit & Physicians for Rural Areas Assistance Program to cover nurse-midwives
• Support the formation of CNM-OB partnerships to provide appropriate care for all women by risk status
Nurse-Midwifery for Georgia
• Excellent outcomes for women & families
• Evidence-based
• Formally educated
• Primary care
• Partnership
• Value
www.georgiamidwife.org
Thank you
Midwifery Care Reduces Cesareans
• Prospective study at community hospital in San Francisco 2005-2014
• Hospital change for labor management in 2011: – Old model: Several obstetricians care for women in labor
– New model: Several Nurse-Midwives care for women in labor with single Obstetrician as backup
• Decreased rate of cesarean delivery following change: – 5% first year
– 2% each year thereafter (32.2% to 25.0% in 9 yrs)
– Highly statistically significant change
Rosenstein et al, 2015. The effect of expanded midwifery and hospitalist services on primary cesarean delivery rates. American Journal of Obstetrics & Gynecology
CNM care
Physician care
The majority of maternal and newborn care ideally provided by a midwife in this framework of quality maternal/newborn care