Envisioning Collaborative
Relationships
Among Midwives and Physicians,
Institutions
Seneca Falls
October 11, 2013
Objectives
After attending this lecture the participant should have increased
knowledge and enhanced competence to
• Identify current interdisciplinary collaborative models between
Midwives and Physicians
• Discuss the regulatory and socially ingrained barriers to successful
collaboration for midwives in different practice settings such as
academic, hospital-based, private practice and home
• Use evidenced-based research to focus policies on outcomes
• Identify practical steps to forging professional, functional and
mutually satisfying relationships with physicians and other medical
providers
• Understand the opportunities for transformation of birth practices
present today
Ellen Biggers, MD, FACOG
Disclosures
• No potential conflict of interest
• Mistaken for a midwife on several occasions
Birth Carving 980 AD
Angkor Wat, Cambodia
Definition of Collaboration
• American College of Nurse-Midwives, 2011.
Collaboration is the process whereby a
CNM/CM and physician jointly manage the
care of a woman or newborn who has become
medically, gynecologically or obstetrically
complicated.
• Webster’s
– To work jointly with others or together especially
in an intellectual endeavor
Historical Perspective on Midwifery in
the US
• Midwives in colonial America were the
dominant attendants at birth
• Late 19th century: Obstetrics created as a
medical specialty, physicians attended half of
the nation’s births. Medical science advances
• Early 20th century: hospitalization for birth
increases, maternal and neonatal mortality
begin to increase in and out of hospital
History Continued
• __ ________ ______ _________
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– ________ ______ __________ __ ___________
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History continued
• Mary Breckinridge founds Frontier Nursing
Service in Kentucky in 1925
• 1931 The Lobenstein Clinic initiated a nursemidwifery education program to serve
disadvantaged women in New York City
• Nurse-midwifery grew slowly in poor
communities both urban and rural and in
home deliveries. (Tom)
History Continued
• 1960’s and 1970’s: California studies reveal
improved outcomes with midwives in rural
underserved areas. (Montgomery 1969 and Levy
1971)
• 1971 ACNM, ACOG, and NAACOG approved a
“Joint Statement on Maternity Care”. The first
recognition of nurse-midwives by a medical
organization (Rooks, 1997)
• 1975 Revision of “Joint Statement” to clarify that
an obstetrician’s presence is not required when
care is rendered by a nurse-midwife
History Continued
• 1978 ACNM redefines nurse midwifery
practice as “independent management of the
antepartal, intrapartal, postpartal, and
gynecological care of essentially normal
women and their normal newborns” (Dawley
& Varney, Burst 2005)
• 2000 ACNM and ACOG define collaboration
between CNMs and Ob/Gyns as one of
“consultation, collaboration and referral”
Collaboration
• American College of Nurse-Midwives, 2011.
Collaboration is the process whereby a CNM/CM and
physician jointly manage the care of a woman or
newborn who has become medically, gynecologically
or obstetrically complicated.
-Joint Committee definition: “The provision of healthcare
by an interdisciplinary team of professionals who
collaborate to accomplish a common goal, and is
associated with increased efficiency, improved clinical
outcomes, and enhanced provider satisfaction.
Current Collaborative Models
• Home Birth
– In 1940 US, the percentage of out-of hospital
births was 44%
– In 2006, National Vital Statistics Report states
there were 24,970 home births in the US or 0.59%
– Prenatal consultation via phone or prenatal visit;
external version for breech, borderline
hypertension
– Intrapartum or postpartum transfer to hospital
CM or FP or OB
Current Collaborative Models
• Birthing Center
– In 2006 there were 10,781 births in a freestanding birth center
– Above collaboration
– Multidisciplinary Team: Midwife, Obstetrician,
Family Practitioner, Pediatrician, Nurses, Doulas
– Policy and Protocol Development
– Quality Assurance
– Regulatory oversight at state and national level
Current Collaborative Models
• Community Hospital
– National Vital Statistics Report: 4.3 million live births in US
in 2006
– Above
– Hospitalists/Laborists
– Nurses, anesthesiologists, administrators
– Hospital department level reporting
– Education programs
– Private practice CM, OB, or combined
– Hospital-based practices
– Financial arrangements
– State agency oversight
Current Collaborative Models
• Tertiary Care Hospital
– Maternal Fetal Medicine
– Residents in OB, FP, ED
– Various departments (Imaging, ED), Programscancer screening, Women’s Health Institute
– Community of Hospitals Reporting, Education
– Policy Making Committees
Characteristics of Successful Models
• Joint Committee Call for Papers (Waldman and
Kennedy 2011)
– Northwest Family Beginnings (Darlington,
McBroom, Warwick, 2011)
– Reasons for success
• Legal framework of independent practice in
Washington State
– Limits vicarious liability for consulting Ob/Gyn
• Clearly delineated scope of practice for each provider
type
Northwest Model
• Institutional culture that supports collaboration
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In-house Ob/Gyn
Regularly scheduled meetings between CNM and Ob/Gyn
Family Practice and Licensed Midwife consultation
Eventual Midwifery Dept: Institutional status, protection to
practice independently and appropriate consultations
» Shared-care model
» On-call team
» Patients attend prenatal visits in their own neighborhood
» Guidelines developed jointly
Licensed Midwives in Northwest
Model
• 1978 Marge Mansfield and Suzy Myers co-founded
the Seattle Midwifery School, became dept of
Midwifery at Bastyr University. Direct-entry 3 year
Masters
• Favorable provider insurance environment
-1996 Malpractice available to LM with “every
category of provider” legislation in Washington.
Insurance contract availability
– LM to CM transfer with ability to give doula
support, resumes care upon discharge
Northwest Definition of Collaboration
• Consultation: CNM seeks the advice or opinion of
Ob/Gyn. CNM maintains management responsibility
for the client. MD does not typically meet patient
• Comanagement: CNM and Ob/Gyn jointly manage care
with CNM primary and MD has direct patient contact
• Referral: the management of all or a very specific part
of a client’s care is transferred to an Ob/Gyn who then
assumes “hands-on” care and responsibility
• Written care plan and roles*
San Francisco General Hospital
Hutchison, 2011
• “Great Minds Don’t Think Alike”
-Shared commitment to excellence in both
providing care to the underserved and training
the next generation of physicians and nursemidwives
• Mutual respect for differences in practice to
capitalize on the expertise of each [type of
provider]
San Francisco General Hospital
Hutchison, 2011
• Independent clinical caseloads, with patient
choice in CNM or obstetric care
• Shared commitment to improving care delivery
systems
• Clear lines of communication that include
guidelines for consultation and collaboration
• Faculty appointments for both obstetricians and
CNMs
• Interdependent responsibility for generating and
managing finances
San Francisco General Hospital
Hutchison, 2011
• Interdisciplinary development of policy
– Uniform use of evidenced-based practice
– Serve on a variety of hospital committees
– Quality assurance initiatives
– Seat at the table
• Interprofessional continuing education
– Obstetric emergency simulation model
– Philosophies of care and benefits of collaboration
SFGH- Effects of Collaboration
• Selective use of Episiotomy
• Intermittent Auscultation
• Centering Pregnancy: group-based model of prenatal
care with Ob resident participation, model used for
breast cancer, chronic pelvic pain and Mother-baby
dyad groups
• VBAC guidelines evidence-based candidate selection
• Postpartum Hemorrhage prevention checklist
• Consultation skill assessment for residents and CNM
students
SFGH- Challenges
•
•
•
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Safety, Autonomy and Power
Ob not comfortable with CNM independence
PROM management differences
State required supervision of nurse-midwives
by physicians in California
Baystate Successful Collaborative
Practice, (Dejoy, 2011)
• Tertiary care, 4,000 births/year
• CNMs have “broad, immediate, and responsive access
to consultation and high-risk care” 3rd and 4th year
residents are used for in-patients and attending
Ob/Gyn for out-patients
• Clear communication, written definitions of
“philosophy, scope of practice, functions and
organizational structure. Details of diagnostic tests and
therapeutic agents that may be independently ordered
by CNMs, conditions requiring consultation,
collaboration, and referral.
Baystate Successful Collaborative
Practice
• Midwifery practice serves a hospital-based office,
four neighborhood health centers, and a
correctional facility
• Midwives provide triage for arriving patients with
obstetric and gynecologic problems. CNM learned
limited U/S, BPP, preterm labor evaluation
• Midwives have primary responsibility for teaching
normal obstetrics and triage to first-year
residents and medical students. Ob Team CNM
Baystate Successful Collaborative
Practice
• CNM primary C/S 9%
• VBAC rate 69%, overall dept rate 13.1 % and
Massachusetts State 8.1%
• Reduced episiotomy and laceration rates
Baystate Successful Collaborative
Practice
• Detailed practice agreement
• Open lines of communication
• Understanding and accepting different
philosophies
• Trust
Obstetrician and Nurse-Midwife Collaboration:
Successful Public Health and Private Practice
Partnership, Shaw-Battista, 2011
• Outcomes of collaborative maternity care for
diverse population in a California community
hospital
• 74% of women received intrapartum CNM
care
• Few differences were seen in management or
outcomes despite significant variation in
demographic and clinical characteristics of
public health clinic patients vs private practice
Shaw-Battista 2011
• Private practice patients: older, less likely
obese, more likely English speaking; more
hydrotherapy, epidurals, and severe
lacerations
• Overall 12.5% Cesarean, less than a quarter
used narcotics, epidural or hydrotherapy.
Shaw-Battista, 2011
• Philosophy of extensive prenatal education,
shared decision-making, and judicious use of
obstetric interventions:
– Optimal labor begins spontaneously
– Labor is permitted to progress without
intervention
– Prenatal education about pharmacologic and nonpharmacologic pain relief methods
– Obstetricians who firmly believe in collaborative
practice model
Shaw-Battista, 2011
– Evidenced based guidelines developed
collaboratively
– Ample hands-on support from nurses, CNM, and
doulas
Shaw-Battista, 2011
• Challenges:
– CNM view childbirth as a physiologic process
requiring supportive care
– Ob view childbirth as process to be managed to
avoid illness and pathology
– Inter-professional consensus on guidelines is timeintensive and therefore expensive
– Patient-centered model respects woman’s right to
decline recommended care
Barriers to Collaboration
• Educational differences
– Level of degree
• Institutionalized discrimination
– Hierarchical system
– Focus on problem cases not overall outcomes
– Legal definitions of relationships between
providers
– Insurance companies
– Hospital departments
Barriers to Collaboration
•
•
•
•
•
Professional competition
Ineffective communication
Gender issues
Social class
Medical malpractice
– Vicarious liability
– Mandates practice composition
– Limits to scope of practice
Barriers to Collaboration
• International Collaboration
– Australia in an attempt to mandate practice
agreements met with complete opposition by
obstetricians and lessened midwife autonomy
– Canada RM are publicly funded, autonomous primary
care providers, required to offer home and hospital
birth. Limited acceptance especially in rural areas
where the patient volume is smaller, doctors bill feefor-service, physician-staffed Medical Advisory
Committees deny privileges to midwives (Munro,
2012)
Peru Surgical Mission
Characteristics of Successful Models
•
•
•
•
•
•
•
•
Joint policy development
Joint responsibility and accountability
Joint education and team drills
Peer review: interdependent independent
practices
Focused on patient outcomes
Evidenced-based practice
Shared work-load and improved outcomes lead
to provider satisfaction
Institutional recognition of autonomy of MW
Normalizing Collaboration
• Current opportunities
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Affordable Care Act
National Maternal Health Initiative
Laborists, “Midwifilist” triage
Maternal Fetal Medicine
Obstetric resident education
Consumer demand
Information availability- shared guidelines, consents,
transport plans, refusal of recommended treatment
forms
Opportunities
• Institute of Medicine (2001,2010)
– care provided by nurses safely reduces health care
costs
– critical to the availability and value of public and
private clinical services
Federal Health Reform:
Implications & Opportunities
• Increased ACNM visibility among policymakers,
other health professions, White House, federal
agencies, and Congress
• Multiple new opportunities for ACNM member
involvement, need for new taskforces, etc.
• Potential for action on multiple issues including
reimbursement, recognition as primary care
providers, education funding, workforce issues,
and issues directly affecting women and families
(Avery, ACNM Focus on the Future, 2009)
Normalizing Collaboration
• Current opportunities
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Affordable Care Act
National Maternal Health Initiative
Laborists, “Midwifilist” triage
Maternal Fetal Medicine
Obstetric resident education
Consumer demand
Information availability- shared guidelines, consents,
transport plans, refusal of recommended treatment
forms
Normalizing Collaboration
• Consensus to eliminate hierarchy
– Clearly defined roles, lines of communication
– Acknowledge history: Control, hostility,
supervision, suppression, nursing dept, ego
• Evidenced-based guidelines: resources
• Interdisciplinary teams
– Capitalizing on the strengths of each provider
– Emergency Scenario Training
– Joint Quality Assurance
Normalizing Collaboration
• Home birth
– HBAC increasing
– Consents for risks and benefits
– Transport plans to hospital
– Referral plans to CNM, MD, MFM
– Acknowledge hostility: unilateral guidelines if
necessary
– WHO observation 82% of births world-wide are
out-of-hospital. In US 1-2%
Normalizing Collaboration
Financial support for collaboration
Educate obstetric and FP residents and
midwives to consult and collaborate
Midwife participation at all levels
Shared work load
Outcomes based assessments
The End
Legislative History NYSALM
• 2003: NYS Legislature passed a bill adding Licensed Midwives to the list
of providers who could order lab tests.
• A.11649 / S.7658 Ch. 524 of 20042007: Physical Therapy bill added
Licensed Midwives to the list of providers who could order physical
therapy evaluation and treatment.
• A.5515 / S.3490 (05-06)2008: A non-discrimination bill was passed that
added Licensed Midwives to the list of providers who could not be
denied hospital privileges solely based on class of licensure. We lobbied
for this bill for seven years before its successful passage.
• A.5505 / A.4019-A2010: The Midwifery Modernization Act amended
the midwifery licensing law which had been passed in 1992. The MMA
removed the requirement that midwives have a written practice
agreement with a physician or hospital, and instead required that
midwives advise their patients of what arrangements were in place in
case the woman needed care beyond the scope of practice of the
midwife. A.8117-B / S.5007-A
Bibliography
• Shaw-Battista J, Fineberg A, Boehler B, Skubic B, Wooley D, Tilton Z.
Obstetrician and Nurse-Midwife Collaboration: Successful Public
Health and Private Partnership. Obstet Gynecol 2011;663-72
• Darlington A, McBroom K, Warwick S. A Northwest Collaborative
Practice Model. Obstet Gynecol 2011;673-7
• Hutchison MS, Ennis L, Shaw-Battista J, Delgado A, Myers K, Cragin
L, Jackson RA. Great Minds Don’t Think Alike: Collaborative
Maternity Care at San Francisco General Hospital. Obstet Gynecol
673-7
• DeJoy S, Burkman RT, Graves BW, Grow D, Sankey HZ, Delk C,
Feinland J, Kaplan J, Hallisey A. Making It Work : Successful
Collaborative Practice
• Conry JA, Inaugural Speech, 64th President of ACOG. 2013
Bibliography
• Garvey, M. Communication: ACNM and ACOG Issue Joint Statement on
Collaboration, 2011
• Brocklehurst P. Perinatal and maternal outcomes by planned place of birth
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• Reiger KM, Lane KL. Working together: Collaboration between midwives
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• Baldwin, LM, Hutchinson,H, Rosenblatt, RA.
Professional Relationships between Midwives
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• Gee, RE, Corry, MP. Patient Engagement and
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