The State of Midwifery (Part 2)

Did you catch part 1? If not, check it out here before reading part 2 today. This was a fun post to put together. To me, this is the every day climb up on Mount Midwifery to make the midwifery profession stronger. It takes every woman, every midwife and every person in between to encourage each other every step of the climb. I truly believe we are stronger together on this journey and that many of the recommendations below will come to fruition in my career. Read on to see how you can help promote, support and lift up midwifery!

First, a disclaimer: many organizations have examined the many facets surrounding the profession of midwifery. The two recommendations that have made the most sense to me are the reports analyzing the trends of midwifery students and the reports analyzing the workforce. Keep an open mind as you read on…to me, there’s not a single facet that is the main contributor to growing the profession. I think some facets have a stronger foothold than others; but mostly, I think awareness of the entirety of issues is the place to start. If we understand where the profession stands now, we can see the potential for the profession if we align to common goals and tasks.

To start, I’d like to analyze the main recommendations from the Midwifery Education Trends Report – 2019 (American College of Nurse Midwives & Accreditation for Midwifery Education, 2019):

Recommendation #1: Increase the number of ACME-accredited midwifery programs

The report breaks this recommendation into smaller recommendations: invest in midwifery education in the 24 states that currently do not have midwifery programs, or in areas where maternal mortality is high and the number of CM/CNMs is low. I don’t know anything about starting a school for midwifery, but I can imagine that it’s a hefty to do. That being said, it doesn’t make sense to have 4 programs in some states and no programs in other states. The other consideration is that midwifery programs must have spots for their students to complete clinicals – for those that don’t know, on average, a midwifery student does 1,000 clinical hours in their training. Many other students are competing for that same clinical spot, and community hospitals or birth centers only have so many clinical spots at a time. OB/GYN residencies play a major part as well in the availability of spots in a community.

The good news is illustrated from a presentation published by Jesse Bushman (Director of Advocacy and Government Affairs) at ACNM (2015): the trend for CNM/CMs is continuing to increase when compared to OB/GYN residents. I think this upward trend is a GOOD thing. #makemoremidwives!

Source: Bushman, J. (2015, November). The role of certified nurse-midwives and certified midwives in ensuring women’s access to skilled maternity care [PowerPoint slides].

I don’t have a lot of wisdom for this recommendation, but I can say this: going forward in your practice, career or pregnancy, keep in mind that where you choose to spend your healthcare dollars matters. If you choose midwifery, you are increasing the demand in the economy for a service that you want. If there is enough demand (and money), that creates a greater demand in a community or state. If you want to move the needle for midwifery programs, start by choosing midwives where ever possible.

Also interesting, is this graph on distribution of OB/GYNs by age…there are a lot of OB/GYNs headed into retirement soon. Remember from part 1: “As of August 2019, the number of CNMs (certified nurse midwives) and CMs (certified midwives) was 12,655 and 111, respectively. In contrast, there were 33,624 OB/GYNs in 2010.”

Do you think that OB/GYNs retiring will help the midwifery workforce or cause a bigger strain on the maternal healthcare system?

Source: Bushman, J. (2015, November). The role of certified nurse-midwives and certified midwives in ensuring women’s access to skilled maternity care [PowerPoint slides].

Recommendation #2: Support and increase federal, state and private funding

This recommendation is broken down into two separate recommendations: first, to increase federal funding for midwifery programs in a fashion similar to how OBGYN training programs are funding, and to encourage private donors or foundations to specifically support midwifery education or programs. How do you increase federal and state funding? You GET INVOLVED! Write a letter to your congressman…ask them to support midwifery and bills aimed at increasing midwifery autonomy and education. I used to work with a midwife that would send a postcard to her Congressman for every baby she delivered. She would include the same simple message: “Congressman, you have a new constituent!” Our government is by the people, for the people; don’t give up before you even try to contact the people that are sitting in the seats making decisions. Can you imagine what would happen if every midwife in the United States sent a postcard to their Congressman for each baby they delivered? What kind of response would we get (and how amazing would that be!)?

Don’t know who your representatives are? Check out the House of Representatives here; check out the Senate here; and if you aren’t registered to vote, now’s the time! It’s an election year…Register here. Congress recently passed a bill for $2.5 million specifically for midwifery education! It’s a start, but there’s a long journey ahead. Read more here.

Recommendation #3: Full practice authority in all 50 states

This one is self explanatory – but for those that are a little confused, can you imagine going to the doctor and after the doctor diagnoses you they tell you they can’t write you a prescription…or give you a certain type of medical equipment you need…all because of their state regulations? Many nurse practitioners face this exact issue in their practice every day. Midwifery is no different. If you’re not sure where your state stands, I encourage you go to the Board of Nursing website for your state and read the scope of practice. I personally read the scope of practice every time I renew my nursing and midwifery licenses – to me, it’s just a good habit to see what has changed in the past 2 years. It also illuminates what changes still need to happen for full practice authority.

Another great way to work towards full practice authority is to advocate for midwifery. This can be done a variety of ways (see above for contacting your legislators – send them post cards about full practice authority too!)…can you think of anything you can do in your community? Get involved with an ACNM affiliate! Even if you aren’t an ACNM member, these midwives meet up on a regular basis and talk about what’s going on in their state and community. It’s a fantastic way to meet midwives near you and talk about your state or community issues together.

Recommendation #4: Equal pay

Equal pay doesn’t mean that midwives should make what an OB/GYN does! It means that midwives should be reimbursed the exact same as the OB/GYN when performing pregnancy care or a vaginal birth. In Alaska, Medicaid only reimburses 85% of what a physician is reimbursed. In a hypothetical situation, if a physician is reimbursed $1000 for a vaginal delivery, the midwife is only reimbursed $850.00 for performing the same skill and procedure. If you know anything about Medicare and Medicaid, know that these are federally funded programs. The annual reimbursements published by these entities guide much of the healthcare reimbursement in the United States. If you are a midwife or a midwifery student, start learning about these concepts sooner rather than later. And again, this is a great thing to send a letter to your legislator about.

Recommendation #5: Interprofessional education

The report recommends increasing models that support interprofessional education models that support midwifery. Honestly, I’m not really sure what the report is intending here, but I will say this. I’ve worked with OB/GYNs and providers that have never worked with a midwife and they just aren’t really sure what midwives can do. Once a provider or other healthcare member has seen what midwives bring to the table, they love midwives! Here’s my recommendation: in everything you do, demonstrate to people that midwives are awesome. I recently went to a combat trauma training for 3 days called Tactical Combat and Casualty Care – man, it was exhausting and eye opening. But, the teachers were amazed that a midwife could put on a tourniquet and handle a mass casualty. What’s more funny, from my point of view, birth and the battlefield both intense environments.

Recommendation #6: Diversify the workforce

Lastly, the report mentions increasing the diversity of the midwifery workforce. There are studies that have demonstrated that patients are more likely to comply and complete recommended care from an individual of their own ethnicity or race. Midwifery is no different, we need more diversity. Have you been wondering if midwifery is for you? Do you have a diverse background or come from a different culture that the United States? Have you ever thought how that would make you an even stronger midwife? Maybe now’s the time for you to consider midwifery school!

Recommendation #7: Make midwifery the standard of care

Okay, this recommendation is my own! Here’s what I love about standards – it’s the foundation everyone starts from. In the United States, the maternity healthcare system is fractured. The system delivers care but every woman receives different care because the system isn’t standardized. My argument isn’t for socialized healthcare, it’s for getting the right people on the bus and then making sure those people are in the right seats.

Here’s a couple of reasons why midwifery is the perfect solution for the maternity system in the United States and why it’s a no brainer to make it the standard of care.

One, OB/GYNs are doing a lot of other cool things other than delivering babes. While they are concentrating on sub-specialities, midwives are capable of managing good, old birth! And we love it.

Source: Bushman, J. (2015, November). The role of certified nurse-midwives and certified midwives in ensuring women’s access to skilled maternity care [PowerPoint slides].

Across, the United States, midwives can fill some significant gaps in maternity care…

Source: Bushman, J. (2015, November). The role of certified nurse-midwives and certified midwives in ensuring women’s access to skilled maternity care [PowerPoint slides].
Source: Bushman, J. (2015, November). The role of certified nurse-midwives and certified midwives in ensuring women’s access to skilled maternity care [PowerPoint slides].

If we assume that the majority of women are low risk in pregnancy…it makes sense for providers that are experts in normal pregnancy to care for them! Based on this data, the majority of pregnancies are low risk.

Source: Bushman, J. (2015, November). The role of certified nurse-midwives and certified midwives in ensuring women’s access to skilled maternity care [PowerPoint slides].

So moving forward, how do we help the state of midwifery? First, remember how every one is trained…a little reminder about the different roads to midwifery:

Source: Bushman, J. (2015, November). The role of certified nurse-midwives and certified midwives in ensuring women’s access to skilled maternity care [PowerPoint slides].

By recognizing that midwives are able to take care of the majority of pregnant women, we can start building better pathways for their training. This process takes EVERYONE! This collaboration model sums up the goal:

Source: Bushman, J. (2015, November). The role of certified nurse-midwives and certified midwives in ensuring women’s access to skilled maternity care [PowerPoint slides].

The presentation by Bushman (2015) also agrees with the Midwifery Education Trends Report – 2019, in recommending revisions to medical school OB rotations, improved payment for supervised services, tax credits for preceptors, improvement for graduate nurse education programs and increasing providers in areas with maternity provider shortages.

Whew…that was a lot about the State of Midwifery! Thanks for hanging in there guys. This is all really important to the profession and every midwife needs to know this information if the profession is going to grow stronger and move forward. I have the third and final part of the series in the works – the last post on the State of Midwifery is about the road ahead for the profession. Stay tuned!

What did you think about the recommendations? Do you think these are too generic or impossible? What have you done in your state or community to help the state of midwifery? What ideas do you have to help the profession?

Can’t wait to see your responses! Want even more? ACNM has a talking points sheet here that speaks to much of what was reviewed.

Happy Monday!

Jamie

References:

American College of Nurse Midwives & Accreditation for Midwifery Education. (2019). Midwifery Education Trends Report – 2019, 1-13.

Bushman, J. (2015, November). The role of certified nurse-midwives and certified midwives in ensuring women’s access to skilled maternity care [PowerPoint slides]. American College of Nursing.

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