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Envisioning Collaborative Relationships


Envisioning Collaborative Relationships Among Midwives and Physicians, Institutions Seneca Falls October 11, 2013 Shaw-Battista, 2011 Challenges: CNM view ... – PowerPoint PPT presentation

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Title: Envisioning Collaborative Relationships

Envisioning Collaborative Relationships
  • Among Midwives and Physicians, Institutions
  • Seneca Falls October 11, 2013

  • 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
  • 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

(No Transcript)
Birth Carving 980 ADAngkor 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.
  • Websters
  • 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 nations 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
  • __ ________ ______ _________
  • _______ ___ ________ ________ _____
  • ________
  • __________
  • _______ ___ ______ ______ ___ __________ _____
    ________ _______ __ _______ ____
  • ________ ______ __________ __ ___________
    ___________ ___ __ _________ ______ ________
    _______ _____ __ ________

History continued
  • Mary Breckinridge founds Frontier Nursing Service
    in Kentucky in 1925
  • 1931 The Lobenstein Clinic initiated a
    nurse-midwifery 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.

History Continued
  • 1960s and 1970s California studies reveal
    improved outcomes with midwives in rural
    underserved areas. (Montgomery 1969 and Levy
  • 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 obstetricians 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

  • 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
  • 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
    free-standing 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),
    Programs-cancer screening, Womens Health
  • 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
  • In-house Ob/Gyn
  • Regularly scheduled meetings between CNM and
  • 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
  • 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
  • Comanagement CNM and Ob/Gyn jointly manage care
    with CNM primary and MD has direct patient
  • Referral the management of all or a very
    specific part of a clients care is transferred
    to an Ob/Gyn who then assumes hands-on care and
  • Written care plan and roles

San Francisco General HospitalHutchison, 2011
  • Great Minds Dont Think Alike
  • -Shared commitment to excellence in both
    providing care to the underserved and training
    the next generation of physicians and
  • Mutual respect for differences in practice to
    capitalize on the expertise of each type of

San Francisco General HospitalHutchison, 2011
  • Independent clinical caseloads, with patient
    choice in CNM or obstetric care
  • Shared commitment to improving care delivery
  • Clear lines of communication that include
    guidelines for consultation and collaboration
  • Faculty appointments for both obstetricians and
  • Interdependent responsibility for generating and
    managing finances

San Francisco General HospitalHutchison, 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

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
  • Postpartum Hemorrhage prevention checklist
  • Consultation skill assessment for residents and
    CNM students

SFGH- Challenges
  • 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

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
  • 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
  • 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
  • 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
  • Prenatal education about pharmacologic and
    non-pharmacologic pain relief methods
  • Obstetricians who firmly believe in collaborative
    practice model

Shaw-Battista, 2011
  • Evidenced based guidelines developed
  • Ample hands-on support from nurses, CNM, and

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
    time-intensive and therefore expensive
  • Patient-centered model respects womans 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
  • 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 fee-for-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
  • 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

  • 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
  • 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
  • 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
  • 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
  • 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 /

  • 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
  • Darlington A, McBroom K, Warwick S. A Northwest
    Collaborative Practice Model. Obstet Gynecol
  • Hutchison MS, Ennis L, Shaw-Battista J, Delgado
    A, Myers K, Cragin L, Jackson RA. Great Minds
    Dont Think Alike Collaborative Maternity Care
    at San Francisco General Hospital. Obstet Gynecol
  • DeJoy S, Burkman RT, Graves BW, Grow D, Sankey
    HZ, Delk C, Feinland J, Kaplan J, Hallisey A.
    Making It Work Successful Collaborative
  • Conry JA, Inaugural Speech, 64th President of
    ACOG. 2013

  • Garvey, M. Communication ACNM and ACOG Issue
    Joint Statement on Collaboration, 2011
  • Brocklehurst P. Perinatal and maternal outcomes
    by planned place of birth for healthy women with
    low risk pregnancies the Birthplace in England
    national prospective cohort study. BMJ
  • Reiger KM, Lane KL. Working together
    Collaboration between midwives and doctors in
    public hospitals. Aust Health Rev 2009
  • Miller, King, Lurie, Choitz. Certified
    nurse-midwife and physician collaborative
    practice. Piloting a survey on the Internet. J
    Nurse Midwifery 1997 Jul-Aug42(4)308-15.
  • Ament, LA, Hanson, L. A model for the future.
    Certified nurse-midwives replace residents and
    house staff in hospitals. Nurs Health Care
    Perspect. 1998 Jan-Feb19(1)26-33.
  • Waldman R, Powell Kennedy H. Collaborative
    Practice Between Obstetricians and Midwives.
    Obstet Gynecol 2011503-4

  • Baldwin, LM, Hutchinson,H, Rosenblatt, RA.
    Professional Relationships between Midwives and
    Physicians Collaboration or Conflict? Am J
    Public Health. 199282262-264
  • MacDorman, MF, Menaker, F. Trends and
    Charcteristics of Home and Other out-of-Hospital
    Births in the United States, 1990-2006. National
    Vital Statistics Report, 2010581-14

  • Gee, RE, Corry, MP. Patient Engagement and Shared
    Decision Making in Maternity Care. Obstet Gynecol
  • Munro, S., et al., Models of maternity care in
    rural environments Barriers and attributes of
    interprofessional collaboration with midwives.
    Midwifery (2012), http//dx.doi.org/10.1016/j.midw

  • Menasche,KA. Collaborative Practice between
    Certified Nurse-Midwives and Obstetricians and
    the Factors in Working Together to Normalize
    Childbirth An Integrative Review, 2013
  • DiVenere, L. Lay midwives and the ObGyn Is
    collaboration risky? OBG Management, 201224
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