1 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 biases D. A relatively new phenomenon 2
3 Midwifery: An Ancient Commitment, A Modern Success Story
4 Midwife Defined Literal 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 physicians CNMs provide primary care beyond labor & birth: Focus on womens specific needs Offer a variety of options Minimize unnecessary intervention
5 CNMs Do More than Birth Care! Scope of Nurse-Midwifery Practice: Pregnancy, birth, & newborn care Womens primary care & health promotion Family planning Advanced clinical practice by some, e.g. first assist in surgery circumcision colposcopy ultrasonography Education Public Health
6 Emphasis on Primary Care Primary Care During Pregnancy Labor & BirthPrimary Care Non-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 & LMs CNMs LMs Formally educated Yes Not necessarily Scope of practice Primary care of across life span Childbearing cycle Prescriptive practice Yes, as APNP Several meds allowed Place of birth All settings Out-of-hospital only Collaboration required Yes No Malpractice coverage Yes No 7 Both are recognized by WI statutes & certified by their respective organizations
8 CNM Advantages Meet requirements: graduate from a nationally accredited education program with masters 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 others Use formal mechanisms to maintain continued competency Continuous improvement with peer review
9 American College of Nurse-Midwives (ACNM) Sets National Standards for Practice Standards for the Practice of Midwifery Core Competencies for Basic Midwifery Practice Peer review Code of Ethics Clinical Bulletins Documents available online at www.midwife.org
10 CNMs Have Availability of Professional Liability Insurance CNM CM [not recognized in WI] ACNM Program Institutional Coverage Private Carriers
Where CNMs practice? Where CNMs attend most births? A.Birth Center B.Hospital C.Home D.Outpatient offices E.Community 11
12 Location of CNM-attended births 97 2 1 0 20 40 60 80 100 Hospital Birth Center Home % 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%
13 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 womens participation in decision-making Use technology & intervention appropriately Available from: www.midwife.org
Areas where CNMs have led providers in applying EBP? A. Food & drink during labor, not NPO B. Intermittent fetal monitoring C.Positions other than lithotomy for birth D.Support of spontaneous pushing E. Non-routine, indicated episiotomy 14
15 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
16 CNMs Use Technology & Birth Interventions Appropriately 0 10 20 30 40 50 60 Cesareans Induction Epidural Continuous EFM Forceps-Vacuum MDs CNMs Percent Rosenblatt RA, et al. Interspecialty differences in the obstetric care of low-risk women. American Journal of Public Health 1997;387:344-51.
17 Unique Points about CNM Practice Offer: Family involvement Continuous labor support Alternative hours to accommodate needs Additional innovative options: Group Prenatal Care Hydrotherapy or Waterbirth
18 CNMs Serve a Wide Variety of Women Our clientele are: 7.5% of all births 10% of vaginal births 50% women of color 16% uninsured 27% immigrants 29% 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.
19 Midwifery Prenatal Care (PNC) Contributes to Excellent Outcomes L if e s t y le A d v ic e E m o t io n a l S u p p o rt P r e g n a n c y a n d B ir th E d u c a t io n L a b o r a t o r y T e s ts a n d M e d ic a l In t e rv e n t io n s M id w if e ry P r e n a t a l C a re 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.
20 CNMs Have Excellent Outcomes 0 1 2 3 4 Infant Mortality Neonatal Mortality Low Birthweight CNMs MDs 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 phenomenon C. Has continued to find similar results over decades 21
Before, During, & After CNM Care: A Classic Study 22
Nurse-midwives quality of care compared to physicians? A. Better on a variety of clinical parameters B. More cost-effective C. Always equivalent D. Consistently inferior as non- physicians 23 See ACNMs QuickInfo on Quality & Effectiveness of Nurse-Midwifery Practice. See ACNMs QuickInfo on Cost Effectiveness . Jacox A. The OTA report: a policy analysis. Nursing Outlook 1987;35:262-7.
24 Patients Prefer Practices with CNM Providers 0 20 40 60 80 100 Percentage Satisfied Use Again CNMs No CNMs 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 dont collaborate, because they are independent providers 25
26 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 practice B. Direct supervision C. Vicarious liability D. Payment required for availability & consultation E. Partners in providing best care for each woman 27
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 28
The CNM group is what size, compared to the types of APNs [NPs, CNMs, CRNAs, CNSs]? A. The largest B. A mid-range size C. The smallest 29
Political Power Leverage our relationship with nursing & APNs