Barnes, Sommer
PM 702 Spring ‘12
Rosenbloom
B ROADENING S COPE OF P RACTICE FOR N URSE -M IDWIVES IN M ASSACHUSETTS :
A P OLICY A NALYSIS
Certified nurse-midwives (CNMs) are advanced practice nurses with special training in pregnancy and delivery as well as women’s general health.
1 Prior to legislation passed earlier this year, CNMs in Massachusetts were required by state law to operate under the direct supervision of a physician. This oversight included approval of prescriptions, tests, and procedures, as well as some observational supervision.
2 In addition, physicians carried ultimate liability for patient outcomes.
3 In February,
Massachusetts Governor Deval Patrick signed into law the House bill entitled “An Act
Relative to Enhancing the Practice of NurseMidwives,” a piece of legislation introduced in hopes of expanding midwifery practice and improving access for all women across the lifespan.
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B ACKGROUND
Newly loosened restrictions on midwifery practice are expected to increase quality of care and cost control through improving efficiency of care delivery, reducing the need for expensive labor interventions, increasing access for underserved populations, and shifting responsibility from physicians to nurses. The bill is the result of years of lobbying by midwifery associations in the state of Massachusetts, following increasing autonomy for CNMs throughout the nation in the face of physician shortages.
2
While all but six states including Massachusetts have had similar allowances in place for years, Massachusetts regulation for CNMs has lagged behind.
3, 5
Policymakers in support of relaxing restrictions on CNM practice predict simultaneously improved access and cost control, claiming that the law will remove barriers to “safe and cost-effective care” that has long been established and accepted

outside of the state of Massachusetts.
4 The result of states’ varying regulations for
APRNs such as CNMs has been a tendency for valuable practitioners to migrate to less restrictive states, leaving some women stranded without care.
1 This law hopes to ameliorate that effect. Furthermore, because nurse-midwives tend to serve recent immigrants and economically disadvantaged populations, 5 access will not only be widened across the board, but will be particularly effective in filling gaps in health equity.
Now that Massachusetts midwives will bear liability for their own patients, they may encounter fewer obstacles to serving the needs of the state’s women. CNMs will no longer be limited by finding a physician willing to take on what may be perceived as a risky clinical partnership, thus reducing barriers to practice.
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C OST AND E FFICIENCY
Like other advanced-practice nurses (APRNs), nurse-midwives have had the ability to write prescriptions in Massachusetts prior to this law.
1 But now midwives will be able to bypass physician go-ahead and provide direct and unsupervised care to patients.
3 Cooperative regulation by the state’s Department of Public Health, the Board of Registration in Nursing, and the Board of Registration in Medicine will oversee the types of medication nurse-midwives are able to prescribe.
2 Nurse-midwives tend to prescribe only routine medications like supplements and contraceptives for well woman care, but such thorough regulation is standard to maintain legitimacy across all levels of healthcare practice.
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Precisely because prescriptions for a characteristically healthy client base are so uncomplicated, individual approval has resulted in redundancy and inefficiency in care delivery. Massachusetts midwife Agnes Densmore describes her experience:
“Physicians at Jordan Hospital right now have to cosign every order and note that CNMs write. This is an [onerous] task for already overworked physicians.” 2 Bill sponsor Rep.
Kay Khan made a similar argument in her testimony to support the legislation, citing
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physician overextension via a “critical shortage of obstetricians and gynecologists.” 7
Recent changes are expected to yield better efficiency in midwifery practice.
V
ALUE AND
Q
UALITY
Despite a possible shortage in care for pregnant women, physician groups like the Massachusetts Medical Society are displeased with the widening scope of practice for midwife paraprofessionals.
5 “Clearly there is no clinical evidence or need for a statutory framework which allows individual nurse midwives the discretion to decide which tests are within their compet ence or area of interest,” read a statement by the
Massachusetts Medical Society. Representatives of the group voiced their own concerns about efficiency, foreseeing the ordering of unnecessary tests and procedures through such “unlimited discretion”.
5 Radiologists and others have argued that nurse-midwives will be unprepared to interpret tests normally read by specialists.
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It would seem that these opposing physician groups envision a mad dash by midwives to perform tests and prescribe pills simply becau se they are now “allowed to.”
What they seem to be missing, is that such extensive interventions are counter to the very core of midwifery practice. As Rep. Kay Khan noted in her testimony to support the bill, it is perhaps this very hospital-based, pathology-focused model of care that has subjected women to expensive and unnecessary interventions and resulted in what we may term “wasteful healthcare spending” as well as distressing rates of infant mortality in the US.
7 One might expect that midwives would, per their extensive training, be able to recognize a problematic pregnancy and consult a physician when appropriate, if care were beyond her scope.
But, as is typical of the beneficiaries of professional monopolies, physicians have an interest in protecting the hierarchical professional structures that keep them in charge and financially secure, even sometimes to the detriment of consumers.
1 In his analysis of value as it relates to healthcare, Michael Porter asserts that because stakeholders are
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many and varied, value must be defined on the customer’s terms alone.
8 Thus, ultimately, value rests on results.
As for how midwives compare to OBGYNs and other physicians that care for pregnant and laboring women, by Porter’s definition, value is comparable if not better. First, midwifery care is traditionally whole woman care.
Therefore, it meets by definition Porter’s criteria for encompassing “all services or activities that determine success in meeting a set of patient needs…defined as an inter related set of medical circumstances that are best addressed in an integrated way.” 8
The same is not necessarily true of obstetricians, for example, whose training is specifically in surgery rather than more broadly defined women’s health. Additionally, midwives have long demonstrated effectiveness in reducing interventions during labor and delivery, including such complicated and sometimes dangerous procedures as cesarean and forceps delivery.
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R OOM FOR I MPROVEMENT
Childbirth currently represents one of the costliest areas of coverage by
Medicaid, but the price of a low-intervention birth led by a midwife is minimal compared to that of the average L&D nationwide, which includes an increasing number of cesarean births.
7 While healthcare expenditures may be lowered by employing CNMs rather than
OBGYNs, however, reimbursement rates for NPs remain low. Compared to physicians,
APRNs are compensated at a rate of about 75-85% for the same services.
1 This could present a barrier to access for those who cannot afford the gap in coverage. Legislation needs to address Medicaid coverage rates for APRNs if the state is to promote employment of midwives.
As in the past, midwives in Massachusetts will be required to belong to a healthcare system and to maintain a “clinical relationship” with an OBGYN.
3 What exactly this entails seems open to interpretation, and seems to have been mandated to placate physician groups. If midwives must maintain a relationship with another practitioner who
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is often thought of as a superior, we risk instilling the notion that, while technically capable, midwives still need some guidance. Such collaborations are often advantageous and desired by midwives and physicians alike, but such partnerships have also resulted in conflicts related to gender and power differences.
10 An article in the
Journal of Nurse-Midwifery concludes that “additional work needs to be done in defining midwifery as distinct from medicine, where both coexist within a collaborative system, without having medicine encompassing midwifery.” 10
This byline impedes such progress by keeping midwives in a hierarchical union with obstetricians. Any midwife invested in protecting the health of her clients and their babies would also see the benefit of coordinating with a physician as a safety-net provider —particularly midwives who are also trained as nurses. It is simply unnecessary to insist upon a relationship she is likely to form anyway, except to appease those in more powerful positions and to maintain a sense of dependence.
Strides are being made in Massachusetts’s regulation of midwifery practice. In coming years, adjustments will likely be made as issues arise in systems of care delivery and payment, and in midwife-physician collaboration. By permitting relationships with general practitioners as well as obstetricians, and through improving reimbursement through Medicaid, the state could further midwives’ ability to practice in Massachusetts, thus promoting access to comprehensive healthcare for women. As with earlier this year,
Massachusetts should continue to look to other progressive states as they increase scope of practice and improve pay equity for midwives.
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REFERENCES
1. Naylor MD & Kurtzman ET. The role of nurse practitioners in reinventing primary care.
Health Affairs. May 2010;29(5):893-899.
2. Meserve C. Nurse-midwives at Jordan Hospital applaud new legislation. Plymouth
Patch (online). 13 Feb 2012 [cited 30 Apr 2012]. Available from: http://plymouth.patch.com/articles/nurse-midwives-at-jordan-hospital-applaud-newlegislation
3. Barr S. Mass. nurse-midwives no longer need physician OK to practice. Kaiser Health
News Blog. 9 Feb 2012 [cited 30 Apr 2012]. Available from: http://capsules.kaiserhealthnews.org/index.php/2012/02/mass-nurse-midwives-nolonger-need-physician-ok-to-practice/
4. The Office of the Governor. Governor Patrick signs legislation to enhance the practice of nurse-midwives in Massachusetts (online press release).12 Feb 2012 [cited 30 Apr
2012]. Available from: http://www.mass.gov/governor/pressoffice/pressreleases/2012/2012202-governor-signsnurse-midwives-bill.html
5. Zimmerman R. A snapshot of massachusetts midwifery care: 6 surprising facts.
CommonHealth.14 Apr 2011 [cited 30 Apr 2012]. Available from http://commonhealth.wbur.org/2011/04/midwifery-care-in-massachusetts
6. Baerlocher MO, Detsky AS. Professional monopolies in medicine. JAMA Feb
2009;301(8). 858-860.
7. Khan K. Testimony in support of H. 2080, An Act Relative to a Board of Registration in
Midwifery. Office of State Representative Kay Khan (online). [cited 30 Apr 2012].
Available from: http://kaykhan.org/index.cfm/page/Testimony-in-Support-of-H.-2080,-An-
Act-Relative-to-a-Board-of-Registration-in-Midwifery/cdid/10625/pid/10226
8. Porter ME. What is value in health care? N Engl J Med (online);363:2477-2481. 23
Dec 2010 [cited 30 Apr 2012] Available from: http://healthpolicyandreform.nejm.org/?p=13328
9. Sandall J et al. Improving quality and safety in maternity care: The contribution of midwife-led care. J of Midwif & Wom Health 2010;55(3):255 –261.
10. Keleher KC. Collaborative practice: characteristics, barriers, benefits, and implications for midwifery. J of Nurse-Midwifery, 1998;43(1): 8 –11.
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