Teaming Up with Our Nurse-Midwife Friends

Earlier this month, I had the good fortune to attend the American College of Nurse Midwives (ACNM) annual meeting in Nashville, TN. What a fabulous meeting in a great location. The meeting program was diverse and holistic, with an emphasis on the same issues ob-gyns are struggling with: improving safety in our birthing centers, improving global women’s health, and changing the delivery of care right here at home so that we see healthier moms and babies.

An ACOG delegation—including myself, Executive Vice President Dr. Hal Lawrence, Past President Dr. Richard Waldman, and President Elect Dr. John Jennings—attended the opening ceremonies and were greeted with a thunder of applause, an acknowledgment that collaboration in improving women’s health and access to care is a shared goal of our organizations. ACNM also gave ACOG a very special award: the Organizational Partner Award for aiding in the development and practice of midwifery. This award was very meaningful to us. It was recognition that ob-gyns and nurse-midwives do collaborate, share delivery services, and very much depend on one another. The changing face of health care ensures that our professions will continue to interact, innovate, and work together.

Change is tough, because often it means separation from our comfort zone and having to adopt different behaviors or different approaches. Some physician practices have quickly incorporated midwives, and others have not. According to trends in the ob-gyn workforce, we do not have enough physicians in our specialty to meet the challenges ahead. The reality as we look toward the future? It is likely that many models of collaborative practice will be adopted by more and more physicians, both out of necessity and because it just makes sense. Expanding our access to patients with physician assistants, nurse-midwives, and nurse practitioners when possible both serves our patients and allows ob-gyns an opportunity to focus on the work that specifically requires our special skill set. We will need to look closely at how we provide care, and particularly on how we collaborate on the delivery of care, over the next decade. I’m personally looking forward to sharing more information on successful strategies to provide our patients with the best coordinated care we can.

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9 thoughts on “Teaming Up with Our Nurse-Midwife Friends

  1. Dear Dr. Conry,

    I am so grateful and enormously heartened to hear that you and your team attended the ACNM conference. It is in both parties best interest to work together, focusing their joined efforts to improve maternity care in the US. I am a VBAC Mom and currently lead a support group of women who as a whole have felt disrespected, manipulated and abused during their pregnancy, labor and deliveries. While I know that there are countless number of ‘good OB’s and midwives’ out there practicing respectful, evidenced based, maternity care where the mother is fully informed of the risks and benefits of all procedures but from my experience they are few and far between.

    It would be wonderful if ACOG would team up with ICAN – the International Cesarean Awareness Network and speak to mothers, many of who feel like this, and discuss what can be done to change the course that the Obstetrical community is headed in. I would be happy to speak in greater length regarding a project like this and to perhaps implement a full scale, integrated program where by Dr’s are required to provide a simple brochure to each patient they feel is in need of an induction or cesarean that gives an overview of the risks and benefits associated with either procedure. That patients are referred to c-section support groups post-operatively. That there is a standard of care across all practices, utilizing evidence and not opinion to develop these standards. That de-facto VBAC bans are removed from hospitals across the country and women are given the opportunity to make their own informed decision regarding their births.

    Thank you for prioritizing this partnership with ACNM as I feel like it can only improve the standard of care to a level we all deserve.

    Sincerely,

    Lauren Pace Specht

  2. Dear ACOG President,

    Thank you for your continued work in building a bridge between Ob’s and Midwives. This work is very important and will continue to be necessary as the years go by. I commend you for attending this event and choosing to take the time to learn about other professions you and other OB’s have not been trained in. Hopefully in the future when those professions ask thru legislation for the ability to practice in our various states, your organization will be able to stand beside them as a supporter and not in opposition.

    I found it interesting you choose to mention that OB’s are struggling to improve safety in Birth Centers. I think if you are going to be effective you should focus your effort on safety in Hospitals. Birth Centers have had excellent outcomes that hospitals in the United States would love to obtain. Their use of the Midwifery Model of Care is probably the single greatest factor in low C-Section rates, low infection rates, low vaginal tear rates, low infant and maternal mortality rates, and extremely high patient satisfaction rates. Further more as you probably know Certified Professional Midwives own and operate more than half of the nations birth centers. Their expertise in their field is contributing to excellent results.

    On the topic of Collaboration. Looking at the state of Delaware is all one must do to see what happens when Doctors ask for a collaborative agreement requirement as a condition of legality and licensure. Doctors in that state for 10 years have banded together to prohibit any Certified Professional Midwives from practicing. We see the same thing in North Carolina where MD’s are dropping their willingness to collaborate in order to control midwives and keep them in line. This type of bullying is often blamed on insurance issues. We the consumer groups intercept memo’s and emails from ACOG, AMA, and other state Medical Unions asking doctors to beware of Midwives, not to collaborate, and to report any birth that looks like it might have been planned at home. We are not easily fooled by the kind and simple use of the word collaboration when its used to control and keep doctors in power.

    We need to find ways to make sure that Consumers can access the provider of their choice so that they can have a safe birth in the location of their choice. After all, Home Birth, Birth Center Birth, and Hospital Birth are all legal options. As a doctor you took an oath to never cause harm. Even if you disagree with the location, i would hope we can all agree on a few things.

    1. If a Birth Center Birth or Home Birth need to transfer to a hospital, communication between the hospital and other location is critical.

    2. All birth attendants should be licensed by a board of their profession. (CPM, CNM, and OB).

    3. OB’s should not be liable for care or decisions that happen in home births or birth centers. OB’s should be able to assist over the phone (Liability Free) if a out of hospital provider has a question.

    4. Women should be fully informed of the risks of birth. It doesnt matter if they are in a hospital, birth center, or at home.

    5. They should be allowed and respected in their refusal of any care offered to them no matter of the location of birth.

    6. Midwives who work in home births should be encouraged and allowed to continue care with their client (who trusts them) after a transfer as it may enable doctors or CNM’s to provide care in a more productive and less hostile manner.

    7. Any form of collaboration that requires one profession to give permission to another profession to practice is unacceptable. This puts liability on OB’s for care they dont provide. Collaboration will only work when OB’s stop opposing Midwife legislation, and start working with them in a respectful manner when the 12% of planned home births transfer to the hospital.

    If we worked on these points I believe that women would be served. Those who want a home birth will have available providers, Birth Centers will function safely as they have been for years, and hospitals will be ready for emergencies and the 98% of women who choose to deliver there.

    The best part with my plan is that OB’s will not have to be the bad guy anymore. Your liability will go down and you will stop having spend millions of dollars preventing families like mine from obtaining CPM’s for our home births. The thing you dont realize is that many families like mine see an OB for all the prenatals in addition to seeing the midwife. This way our OB knows us before hand in case a transfer is needed. We have to do that secretly because if the OB knew they would drop us from the practice. If they really cared about safety they would keep us and watch my wife closely. They would want to know everything they could just in case. Sadly that is not what they are interested in.

    I thank you once again for attending the ACNM event. I have hope that maybe you will understand the fundamental flaws in ACOG’s past approach to out of hospital birth and midwives. Perhaps you will be the leader we hope you are and make the needed changes.

    Jeremy Galvan
    President
    Maryland Families for Safe Birth

  3. Dear Lauren,
    I appreciate your taking time to comment on my blog. I believe everyone caring for women truly believes they are doing the right thing and providing the best care. Our frame of reference is always a reflection of our personal experiences and our training, hopefully combined with the research that helps us answer questions.

    First, I’d like to say that ACOG meant no disrespect for your support group. Sometimes our judgment comes out forcefully as much out of concern for what can happen as it is based on what we have actually seen happen. I think that contributes to a high cesarean delivery rate. I personally practice in an environment where we are able to encourage VBACs, but I also understand the medical-legal pressures that influence decisions regarding VBACs.

    Our organization goes to great lengths to evaluate information and advise ob-gyn practice, and we encourage our Fellows to share this information broadly. To this end, ACOG has created informational brochures for doctors’ offices and patient education FAQs to help explain the risks and benefits of cesareans and VBACs. I’ve provided links below that I invite you to read and share.

    Patient Education FAQ on Cesarean Delivery: http://ow.ly/m3czV
    Patient Education FAQ on VBAC: http://ow.ly/m3cjL
    News Release on ACOG VBAC Recommendations: http://ow.ly/m3cMU

    Caring for women requires collaboration, respect, and a shared goal of helping mothers and babies be as healthy as they can be.

    Jeanne A. Conry, MD, PhD

  4. Dear Jeremy:
    I appreciate your taking time to comment on my blog. Certainly our greatest successes come from true collaborative efforts and an understanding of risks, benefits, and a family’s decision-making process. While ACOG believes that hospitals and birthing centers are the safest setting for birth, we fully respect the right of a woman to make a medically informed decision about delivery.

    I can personally attest that my collaboration with midwives has been very rewarding, and I daresay that the midwives I work with feel that collaborating with physicians can be very rewarding. ACOG and ACNM are sharing ideas on improving our relations, by collaborating on a host of well-woman and maternity projects. As you point out, communication, respect, and access to both training and information will be key in all of our efforts. I know that we are all dedicated to providing the best care possible, and the women nationally and internationally will benefit.

    Jeanne A. Conry, MD, PhD

  5. Dr. Conry, I appreciate that you are offering your thoughts and responses to readers on collaborative efforts between ob’s and midwives. It is very good to get the conversation going, though admittedly discussions are not easy. As you note, it is important to focus on the provision of the best care possible to women and their families– but also recognize that “best care” may respectfully be defined in different ways by different women and maternal health care providers. I hope you will continue to encourage ACOG members to support legislation at the state level to permit each provider to practice to the full extent of her or his training and capabilities. These legislative efforts are particularly important for those women who live in rural communities where there is often a lack of access to quality care. Again, thank you for continuing the discussion!

  6. As a CNM, I applaud your stance on collaborative care and hope that we can see momentum in the legislative process to allow such models of care. I work as a CNM in NC and we were unable to have our practice act changed to a collaborative agreement despite what the evidence shows. This has restricted access to care in our state and it shows in terms of our infant mortality/ morbidity rates. Thank you for your continued support in helping women, families, and babies.

  7. Dear Dr. Conry,
    So happy you attended the ACNM conference. You have inadvertently neglected to refer to all of ACNM’s member midwives who are not only CNMs but are CMs. A certified midwife (CM) is an individual educated in the discipline of midwifery, who also possesses evidence of certification by the American Midwifery Certification Board, the same board that certifies CNMs. We work as full-scope midwives in all practice settings, and at least here in NYS are fully integrated into the health-care system as Voluntary Attendings in many hospitals, either as an employee or in private practice. Women want midwives, and we hope our OB colleagues continue to collaborate with all licensed and certified midwives across the country.

  8. Thanks for discussing the definition and role of the CM within the mid-wife profession and in your setting in particular. ACOG supports both CNMs and CMs—(http://bit.ly/12Y8QmF)— and recognizes the important role of CMs in both ACNM membership and in collaboration with ob-gyns.

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