Choices
and the Midwifery Model of Care:
LACE
for CNMs and DEMs:
Cost
of Maternity Care and Birth Centers:
Thursday, May 3, 2012
Myths and Perceptions:
·
Myth: All midwives
practice illegally.
o Most
people do not understand that there are five different kinds of midwives, and
associate the word midwife with “lay midwives” or “granny midwives”. Certified
nurse-midwives practice legally, and have prescriptive authority, in all 50
states, the District of Columbia, American Samoa, Guam, and Puerto Rico.
Federal law considers CNMs to be primary care providers.
·
Myth: Midwives are
uneducated.
o Starting
in 2010, the minimal requirements for entering into practice as a CNM/CM are a
graduate degree. Approximately 82% of CNMs have a master’s degree, and 4.8% are
prepared at the doctorate level.
·
Myth: Midwives only do
home births.
o Of
the CNM/CM attended births in 2009, 96.1% occurred in hospitals, 2% took place
in free-standing birth centers, and only 1.8% occurred in homes.
o Midwives
offer reproductive and primary care also.
·
Myth: You must go
“natural” if you choose a midwife.
o Midwives
may encourage alternatives to pain medication during labor, however each
patient is encouraged to seek the best pain management option for them.
o If
your plans for birth were at home or a free-standing birth center, making the
decision to receive and epidural will mean being transferred to the hospital.
In most cases, your midwife will be allowed to stay with you for support.
For
one-on-one personalized care of the healthy woman and pregnancy, choose a
midwife!
What is a Birth Center?
·
Birth centers are
home-like structure that may be free-standing, or located within an existing
healthcare system, that offers care to low-risk women throughout pregnancy,
labor, and delivery. Their program of care is based on the wellness ideology of
pregnancy and birth being normal
·
Birth centers offer
family-centered care of the healthy woman before, during, and after normal
pregnancy, labor, and birth. Some of these facilities have their own laboratory
services, offer child birth education, home visits, extra office visits if
needed, and the initial newborn exams
·
Birth centers, through
studies, have proven to have comparable intrapartum and neonatal mortality
rates to those of low-risk hospital births. Birth centers are responsible for
meeting regulations of the state in which they are located for licensure. These
centers must follow stringent rules found in the National Standards for Birth
Centers, through Continuous Quality Improvement Program for Birth Centers, and
they must be accredited by the
Commission for the Accreditation of Birth Centers.
*(Below you can add information specific to your community with linke for your area).
·
There are no
free-standing birth centers in Alabama, but there is a large healthcare system
in Birmingham, AL. that has built a new women’s center allowing patients some
labor choices. However, there are no CNMs on staff.
·
The state of
Georgia is more accepting of the midwifery model of care. There is presently
one accredited free-standing birth center located in Savannah, GA., and plans
are in the works for one in Atlanta, GA.
Brookwood
Women's Medical Center
Safety and outcomes of CNM care
·
The American Journal
of Public Health published a statement that births attended by CNMs are as safe
as those attended by physicians.
·
Women receiving care
from physicians are three times more likely to receive an episiotomy and twice
as likely to receive induction medications and/or cesarean sections than women
being care for by midwives.
·
The Cochrane Pregnancy
and Childbirth Group found that midwife-led care is associated with several
benefits for mothers and babies and had no adverse effects.
·
In matching study
populations, midwives provide outcomes as safe as physicians with a lower rate
of cesareans, use of oxytocin and epidurals as well as a lower rate of low
birth weight infants.
Why do we need to add midwifery?
·
A Healthy People 2020
goal is to improve the health and well being of women, infants, children and
families. Having a healthy pregnancy and breastfeeding are two of the
interventions mentioned in HP2020 that midwifery care has been shown to have a
positive impact on.
·
Improved access to
midwifery care can help in achieving this goal as a few of the Hallmarks of
Midwifery Care include health promotion, disease prevention and health
education, promotion of family centered care, and facilitation of healthy
family and interpersonal relationships.
· *(Post information specific to your community here).
Manistee
County is currently in great need of primary care provides with the resident to
provider ratio being 2,051:1. Midwives provide primary care to women across
their lifespan, not just pregnancy care.
·
The average cost of a
homebirth with a CNM is about 68% less than a comparable hospital birth. Cost of Midwifery Care
·
In 2007, the national
average cost of giving birth in a birth center was $1,872, the average cost for
an uncomplicated birth in a hospital was $8,316. Transforming
Maternity Care
“Why Choose a Midwife?” While this video is
specific to Massachusetts, it can easily be applied to any or all states. Why
Choose a Midwife?
How is midwifery care different than obstetrician care?
·
Midwives focus on
normal pregnancy and birth and are the best option for healthy women whereas
obstetricians focus on the potential for pathology and are therefore the better
option for women with a very complicated health history or pregnancy.
·
Midwives care for the
whole woman and consider all aspects of her personal and family life as vital
pieces of information.
·
Midwives seek to
create a partnership with the woman, viewing her as a unique individual and
educating her to help her become the expert on her own body, promoting health
and encouraging the woman to have an equal voice in her own care decisions.
·
Obstetricians seek to
“manage” a woman’s care as they often consider themselves to be the expert.
When relating to pathologic conditions, they are the experts and an essential
part of the care team, but they often fail to recognize normalcy,
over-emphasizing the potential for pathology.
·
Midwives seek to
minimize the use of pathology oriented interventions whereas obstetricians tend
to rely on them on a routine basis.
·
Women receiving care
from a midwife are more likely to experience: no intrapartum
analgesia/anesthesia, attendance at birth by a known provider, spontaneous
vaginal birth, initiation of breastfeeding, and a higher perception of control
during labor.
·
While not
representative of each and every provider, this short, comical video
demonstrates the general differences in the OB/GYN model versus the Midwife led
model of care. OBGYN v.
Midwife
Licensure, Education, Accreditation, and Certification of Midwives
·
How
are midwives licensed?
o
Certified nurse-midwives (CNMs) are
licensed through their state’s board of nursing, midwifery board, or medical
oversight board. *(This is where you will place information specific to your state). Nurse-midwives in Indiana are regulated as independent
practitioners under the Indiana State Board of Nursing. Indiana regulations
require a nurse-midwife to obtain a written collaborative agreement with a
physician or obtain hospital privileges. ACNM: Our Credentials
*(Below you will place information specific to your state).
o
Nurse-midwives obtain an
Indiana license through submission of an application and a small fee to the
Indiana Professional Licensing Agency. Proof of an active, unrestricted
registered nursing license, graduation from an accredited nurse-midwifery
program, and successful passing of the national certification exam is required.
Once obtained, licensure must be renewed every two years.
o
Licensure varies for direct entry
midwives (DEMs). Currently, twenty-one states offer licensure or regulation to
DEMs. Generally, these states have a midwifery board that oversees and licenses
DEMs. Requirements for licensure vary state to state and may include
certification through the North American Registry of Midwives, graduation from
an accredited midwifery program, and continuing education. Midwives Alliance of North America
Legality of DEMs
·
How
are midwives educated?
o CNMs
are first registered nurses. They must complete a graduate level, accredited
midwifery program with supervised clinical experience in at least one birth
setting: hospital, birth center, or home. The nurse-midwifery program at
Frontier Nursing University, for example, requires nine terms of didactic and
clinical education with a minimum of 675 clinical hours in practice. Frontier Nursing
University
o DEMs
may come from many educational backgrounds such as apprenticeship, accredited
non-nurse-midwifery programs, correspondence programs, or self study. In states
where DEMs are licensed, education requirements are decided by each state’s
licensing body.
·
Are
midwifery programs accredited?
o Accreditation
for midwifery programs is granted and maintained through the Accreditation
Commission for Midwifery Education (ACME). ACME accredits both CNM and direct
entry midwifery programs and is recognized by the U.S. Department of Education.
Currently, the University of Indianapolis is the only accredited
nurse-midwifery program in the state of Indiana. There are several online,
accredited programs available to Indiana residents, including Frontier Nursing
University, the oldest and most prestigious nurse-midwifery school. ACNM: Accreditation
o Accreditation
is offered for direct entry midwifery programs through the Midwifery Education
Accreditation Counsel. These programs prepare DEMs to pass the exam and skills
testing required for certification through the North American Registry of
Midwives. MEAC
·
How
are midwives certified?
o
The American Midwifery Certification
Board (AMCB) awards and maintains certification for nurse midwives in the
United States. Initial certification is obtained by passing the national
certification exam that tests candidates on antepartum, intrapartum, postpartum,
newborn, well-woman gynecology, primary care, and professional issues. ACMB
o
In order to sit for the exam, candidates
must provide proof of a registered
nursing license active within the United States,
have fulfilled the requirements of a graduate level nurse-midwifery
education program accredited by ACME, and have a letter of verification from
their program’s director. Nurse-midwifery candidates must pass the national
certification test within 24 months of graduation with a maximum of four
attempts.
o
Once initially certified, nurse-midwives
must recertify every five years through AMCB. Nurse-midwives must complete
three continuing education modules covering three practice areas:
antepartum/intrapartum, postpartum/newborn, and gynecology/primary care. In
addition to the practice modules, nurse-midwives must complete two continuing
education units equal to 20 hours of study.
o Certification
is available for DEMs. Some states in the U.S. recognize the Certified
Professional Midwife certification offered through the North American Registry
of Midwives. Certification requires documentation of clinical experience in an
out of hospital birth setting and passing of a written exam and skills
demonstration. NARM:
Certification
·
What
is the scope of practice for midwives?
o The
scope of practice for CNMs includes primary care of women from adolescence
through menopause. Gynecological care is provided, including family planning,
preconception care, treatment of sexually transmitted infections for women and
their partners. Comprehensive maternity care is provided including prenatal,
antenatal, postpartum, and newborn care up to 28 days. CNMs order and interpret
diagnostic tests, prescribe medications, perform complete physical exams, and
manage care. ACNM:
Our Scope of Practice
o The scope of practice for nurse-midwives is defined within the
Indiana Nurse Practice Act as the practice of nursing, well woman gynecology,
family planning, antepartum, intrapartum, postpartum care, and the treatment of
health problems for “the normal and expanding family”
o
In order to have prescriptive
authority in Indiana, nurse-midwives must have a written collaborative
agreement and proof of successful completion of two semester hours of a
graduate level pharmacology class. Prescriptive authority is maintained by
completing 30 CEUs, eight in pharmacology, every two years (Indiana Nurse Practice Act, 2007b).
Controlled substances may be prescribed after obtaining an Indiana controlled
substances registration and federal registration with the Drug Enforcement
Administration (Indiana Nurse Practice Act,
2007b).
o
The scope of practice for direct entry
midwives may be defined by the state in which they practice. It is usually
limited to maternity services as prenatal, antepartum, postpartum, and limited
neonatal care. DEMs cannot prescribe medications or order diagnostic tests.
History of Midwifery in the US
·
Beginning –
Midwives have been catching babies in the United States since before it
officially became the United States!
o Midwifery
was a respectable profession valued by colonists, settlers, Native Americans,
and African slaves.
o Many
midwives (as well as doctors) trained as apprentices, by watching and learning
from other midwives.
o Prior
to the late 1700’s birth was considered normal and was only attended by doctors
if there were complications. Often there were no doctors available even if
there were complications.
o No
licensure or specific training required until 1716 and even then only in a few
cities.
·
Changes
o In
the late 1800’s midwives were still attending the majority of births.
o Most
doctors were only delivering babies of wealthy white women in urban areas,
often using forceps and drugs such as opium and laudanum.
o By
the 1950’s hospital births became the norm with doctors delivering the majority
of babies in the U.S.
o Midwifery
practice was almost abolished, with medical leaders portraying childbirth as a
perilous condition and midwives as being incompetent.
·
Growth
o As
traditional midwifery practice decreased in the U.S. a new form of midwifery
began to emerge with nurses acquiring additional education and training to
become nurse-midwives.
o Nurse-midwifery
programs in the 1930’s, such as Frontier Nursing Service and midwifery programs
created by Indian Health Services, lead the way to the re-growth of midwifery
in the U.S.
o By
the 1960’s women became vocal about their discontent with the medicalization of
childbirth as nurse-midwives developed an organization to standardize their
profession.
o The
1970’s saw the opening of the first freestanding birth center in the U.S. with
midwives offering women a choice other than giving birth at home or in a
hospital.
o Certified
Nurse-Midwives have grown in numbers in the U.S. from 275 in 1963 to over 7,000
today and growing.
·
Current
o Internationally
§ The
majority of women in most industrialized nations choose midwifery care for
childbirth, including Austria, Sweden, the United Kingdom (UK), the
Netherlands, Australia, and New Zealand.
§ Midwives
are the primary childbirth attendants in most third world countries as well.
§ Midwives
attend 70% - 80% of births in Sweden, the UK, and New Zealand.
o Nationally
§ Midwives
attend 8% of all births in the U.S.
§ CNMs
attend over 11% of vaginal births in the U.S.
§ CNM’s
practice in all 50 states and the District of Columbia.
§ CPMs/CMs/LMs
practice legally in 29 states.
o Locally *(This is where you will list information specific to your community and practice).
§ CNMs attend 5 out of every 100 births in Tennessee.
§ CNMs attend hospital and birth center births in Tennessee.
Birth Choices
*(Here you will list avaible providers and birth settings in your community)
·
Choices of birth
provider
o M.D.
or D.O.
§ General
Practitioner offering obstetrical services
§ Obstetrician
o Certified
Nurse-Midwife (CNM)
o Certified
Professional Midwife (CPM)
o Certified
Midwife (CM)
o Licensed
Midwife (LM)
·
Choices of birth place
o Hospital
o Birth
Center attached to hospital
o Freestanding
Birth Center
o Home
Here
are some links that may help you discover what choices are available to you and
understand more about the midwifery model of care:
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