Addressing the Shortage of Maternal Care Providers Lisa Kane Low, PhD, CNM, FACNM, FAAN, President, American College of Nurse-Midwives Associate Professor, University of Michigan School of Nursing, Dept. OB/GYN
Projected Numbers of Women, 2015-2060 190,000,000 170,000,000 150,000,000 130,000,000 110,000,000 90,000,000 Nearly 44 million more women (12 million of childbearing age) will need care in 2060. Age 15+ Age 15-49 70,000,000 50,000,000 2014 2016 2018 2020 2022 2024 2026 2028 2030 2032 2034 2036 2038 2040 2042 2044 2046 2048 2050 2052 2054 2056 2058 2060 Sources in Notes View.
Obstetrician/Gynecologists per 100,000 PopulaLon Data Current as of 2011 ACOG eslmates that in 2011, there were 9.5 million people living in a county without a single OB/GYN. OB/GYNs per 100,000 0 0.1 29.9 30.0 + Out of 3,142 U.S. CounLes, 1,459 (46%) have no OB/GYN. Sources in Notes View.
CerLfied Nurse-Midwives per 100,000 PopulaLon Data Current as of 2011 CNMs per 100,000 0 0.1 4.9 5.0 + Out of 3,142 U.S. CounLes, 1,758 (56%) have no CNM. Sources in Notes View.
CNMs and OB/GYNs per 100,000 PopulaLon Data Current as of 2011 CNMs & OB/GYNs per 100,000 0 0.1 29.9 30.0 + Out of 3,142 U.S. CounLes, 1,263 (40%) have no CNM or OB. Sources in Notes View.
Family Physicians PracLcing High-Volume Obstetric Care Have Recently Dropped by One-Half Tyler et al. Am Fam Physician. 2017 Jun 15;95(12):762.
First-Year OB/GYN Residents and Newly CertiLied CNMs/CMs, 1979-2014 2,000 1,800 1,600 1,400 The number of medical graduates entering OB/GYN residencies has remained relalvely flat for three decades. New CNMs/CMs have been increasing recently. 1,200 1,000 800 600 400 200 0 1979 1987 1993 1998 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 1st Year OB/GYN Residents Newly CerLfied CNMs/CMs Sources in Notes View.
Bottom Line: Serious Challenges Serious challenges with ensuring skilled acendants at birth StaLc OB/GYN residencies, SubspecializaLon, rising but small # CNM/CM graduates Changes in provider demographics Increasing palent needs Using a measure of demand that takes into account populalon, prevalence and incidence of condilons and disease, as well as rates of insurance coverage, available supply of providers and ullizalon of care, ACOG has projected a shortage of between 15,723 21,723 OB/GYNs by 2050. Sources in Notes View.
DeLining Terms CNMs, CMs and CPMs Unless speci*ically noted, this presentation focuses on the practice of Certi*ied Nurse- Midwives (CNMs) and Certi*ied Midwives (CMs). CNMs are educated in two disciplines: midwifery and nursing. They earn graduate degrees, complete a midwifery education program accredited by the Accreditation Commission for Midwifery Education (ACME), and pass a national certi*ication examination administered by the American Midwifery Certi*ication Board (AMCB) to receive the professional designation of CNM. CMs are educated in the discipline of midwifery. They earn graduate degrees, meet health and science education requirements, complete a midwifery education program accredited by ACME, and pass the same national certi*ication examination as CNMs to receive the professional designation of CM. There are approximately 11,300 CNMs and CMs in the US and 95% of the births they attend occur in hospitals. CertiLied Professional Midwives (CPMs) may come through one of several educational routes, though they are largely educated through a non-accredited apprenticeship model. There are approximately 1,800 CPMs in the US and 83% of the births they attend occur in an out of hospital setting. States may license midwives who are not CNMs/CMs/CPMs based on state based criteria and their services are focused on care in the home or birth center setting (e.g. LM)
Midwifery Workforce Impact UNFPA State of the World s Midwifery - 2014 87% of the essential care for women and newborns can be provided by an educated midwifery workforce. The Lancet Series on Midwifery - 2014 Provision of accessible quality midwifery services that are responsive to women s needs and wants should be part of the design of health-care service delivery and should inform policies related to health workforce in all countries. The Lancet Series on Maternal Health - 2016 High-income countries with a combination of lowest intervention rates, best outcomes, and lowest costs have integrated midwifery-led care through different models, including team-based care in maternity hospitals, low-risk units alongside full-scope maternity hospitals, and freestanding or home-based midwifery.
DeLinition/Scope of Practice Midwifery as practiced by certilied nurse-midwives (CNMs) and certilied midwives (CMs) encompasses a full range of primary health care services for women from adolescence beyond menopause. These services include primary care, gynecologic and family planning services, preconception care, care during pregnancy, childbirth and the postpartum period, care of the normal newborn during the Lirst 28 days of life, and treatment of male partners for sexually transmitted infections.
Inter-Professional Collaboration The Ideal Lower Risk PaLents Moderate Risk PaLents Higher Risk PaLents Midwife-Led Care Jointly-Led Care Physician-Led Care The right care at the right +me in the right place by the right provider(s) Sources in Notes View.
Laws and Regulations Affecting Access to Midwifery Care and Opportunities to Expand the Maternity Care Workforce
Promoting Full Practice for Midwives What is Full Practice? CNM/CM s able to practice to the full extent of their education and training Independent licensure, does not require supervision of legislate collaborative agreements JOINT STATEMENT OF PRACTICE RELATIONS BETWEEN OBSTETRICIAN GYNECOLOGISTS AND CERTIFIED NURSE- MIDWIVES/CERTIFIED MIDWIVES To provide highest quality and seamless care, ob-gyns and CNMs/CMs should have access to a system of care that fosters collaboration among licensed, independent providers.
Number and Density of CNMs/CMs 428 WA 101 NH 1080 CA 335 OR 96 AK 43 NV 61 ID 228 AZ 150 UT 46 MT 25 WY 213 NM 52 HI 395 CO 17 ND 34 SD 482 TX 48 NE 85 KS 63 OK 305 MN 109 IA 98 MO 30 AR 50 LA 218 WI 463 IL 35 MS 173 IN 371 MI 218 TN 49 AL 121 KY There were a total of 11,725 CNMs/CMs as of May 2017. 377 OH 483 GA 64 WV 75 VT 120 SC 399 NC 681 FL 469 PA 289 VA 976 NY 299 NJ 290 MD 105 ME 36 DE 438 MA 61 RI 190 CT DC 42 Density of CNMs/CMs per 100,000 Pop. 1.00 2.49 2.50 3.49 3.50 4.49 4.50 5.49 5.50 13.00 Source: Number of cer?ficants per AMCB, May 2017. (see: hjp://www.amcbmidwife.org/docs/default-document-library/number-of-cnm-cm-by-state---may-2014- present.pdf?sfvrsn=2) Popula?on figures are 2016 es?mate from US Census Bureau, rounded to nearest 1,000. (see: hjps:// www.census.gov/data/tables/2016/demo/popest/state-total.html)
SOP Laws, Nurse-Midwifery Workforce, and Childbirth Procedures and Outcomes States with autonomous midwifery practice have a mean of 4.85 CNMs per 1,000 births, compared with 2.17 CNMs per 1,000 births in states where CNM practice is subject to supervision or collaborative agreement (p <.01). States with regulations that support autonomous midwifery practice have a larger nurse-midwifery workforce, and a greater proportion of CNM-attended births. Correlations between autonomous practice laws and better birth outcomes suggest future policy efforts to enhance access to midwifery services may be bene*icial to pregnancy outcomes and infant health. Yang et al 2016 J. Women s Health Issues May-June; 26(3): 262-7
ACNM-ACOG Maternity Care Education and Practice Redesign Joint project of ACNM and ACOG funded by the Josiah Macy Jr. Foundation Goals: Develop a model IPE curriculum for ob-gyn residents and graduate midwifery students Address maternity workforce shortages
ACNM-ACOG Maternity Care Education and Practice Redesign 4 demonstration sites, 3 year project Develop and implement didactic modules, laboratory simulation and clinical experiences ACNM and ACOG accrediting agencies are working together to develop joint IPE requirements
University Models to Support Educating midwives in rural settings Distance Learning Approaches Commitment to placements in rural clinical settings. Example: Frontier Nursing University: Current (August 2017) total enrollment of 831 students in clinical sites in all 50 states
Potential Solutions: The Graduate Nurse Education Demonstration $200 Million given to 5 hospitals over 4 years Hospitals partner with schools of nursing and community clinical sites to provide clinical educalon for more advanced praclce nurses. Sources in Notes View.
Potential Solutions: Georgia Preceptor Tax Incentive Program Certain medical, NP and PA students. Each 160 Hours. $1,000 Tax DeducLon. 480 hours of preceplng to qualify. Maximum deduclon = $10,000 Sources in Notes View.
Potential Solutions: Reimbursing Midwife Educators Medicare pays teaching physicians for the services of the interns/residents that they are educalng. CNMs/CMs frequently provide educalonal oversight to medical interns/ residents and student midwives. There is no Medicare policy ensuring payment for services overseen by CNMs/CMs. Hospitals are discouraged from fostering inter-professional educalon or supporlng midwifery educalon. LegislaLon is needed to ensure that when CNMs/CMs oversee services performed by medical interns/residents or student midwives they can be paid for those services, just as teaching physicians are currently paid. Sources in Notes View.
Way Forward.. The team, the team, the team. Bo Schembechler Collaboration, Collaboration, Collaboration UnaJributed
Lisa Kane Low PhD CNM FACNM FAAN kanelow@umich.edu