Licensed Midwives in Rural Health Care Providers Presentation

License Midwives as Rural Health Care Providers Kate T Finn, MS, LM Vice President and Chair, Quality Committee

No Conflicts of Interest to Disclose Kate T Finn, MS, LM Vice President, New York State Association of Licensed Midwives (NYSALM) Chair, Quality Committee and Home Birth Integration Initiative Delegate, National Home Birth Summit and Collaboration Task Force Private Practice Licensed Midwife for 30 years Attending births in rural hospital, birth center and homes

Presentation Overview Overview of Midwifery in New York State Professional Education and Licensure Scope of Practice, Midwifery Model of Care Collaborative Care with Specialty Providers Cost Effectiveness Midwifery in Rural Health Context System Barriers to Midwifery Practice Midwives Deliver High-Value Care

Regulated by Board of Midwifery Masters-level education for licensure National certification by American Midwifery Certification Board (AMCB) Identical practice status and scope for Certified Nurse Midwives (CNMs) and Certified Midwives (CMs) Full scope practice Prescriptive privileges Practice in all care settings Medicaid and private insurance Malpractice insurance New York

Midwifery Demographics in NY New York has 1011 Licensed Midwives Vaginal deliveries in NY 10.6 % of Total NY Births in 2015 Medicaid 53% Statewide Midwives Obstetricians ~ 400 midwifery practice sites Family doctors ~103 hospitals ~2 free-standing birth centers Physician Assistants 1% Total NY Births in home setting

Licensed Midwives in Primary Care Annual exams Reproductive health visits Problem visits Writing prescriptions Counseling Patient education Primary Clinical Responsibility identified by CNM/CMs 53.3% reproductive care 33.1% primary care Fullerton J, Schuiling K, Sipe TA. Findings from the Analysis of the American College of Nurse- Midwives Membership Surveys: 2006 2008. Journal of Midwifery & Women s Health 2010; 55: 299-307.

Midwives Provide High-Value Care Within the Quality Framework Institute of Healthcare Improvement: Triple Aims Improving experience of care for the individual and family Improving health outcomes Lowering health care costs Institute of Medicine: Quality Domains of Healthcare Safe Effective Patient-centered Timely Efficient Equitable

MAXIMIZING MIDWIFERY to Achieve High-Value Maternity Care in New York Choices in Childbirth, 2018; Photo Credit: The Business of Being Born

MIDWIFERY MODEL OF CARE Woman- and family-centered, individualized care Evidence-based practices Shared decision-making and respectful treatment A preventative and comprehensive view of health Relationship-based care Meeting the needs of vulnerable populations A collaborative health care team model Photo Credit: Mario Cassase

Hallmarks of Midwifery Care Evidence for Safe Practice -- ACOG Committee Opinions #687 (2017), #684 (2017), #658 (2016), Safe Prevention of Primary CS (2016) Individualization of care One-on-one care Active labor starts at 6 cm Intermittent auscultation of FHT Drug-free pain relief measures Intact amniotic membranes Expectant management of term ROM Oral intake Unrestricted and upright positions Rest and spontaneous pushing Skin-to-skin contact Physiologic cord clamping Immediate breastfeeding support Safely reduce primary cesareans

Team-Based Care Midwives are independent providers Midwives initiate collaborative care with specialty providers when indicated by the patient s condition

BENEFITS OF MIDWIFERY MODEL Breastfeeding initiation Positive experience Patient satisfaction Sense of control and confidence Vaginal birth after cesarean Cost savings for care Cesarean Section Episiotomy Serious Lacerations Use of Pain Meds Epidural/Spinal analgesia Continuous Electronic Fetal Monitoring Vacuum/Forceps Extraction Induction of Labor Augmentation of Labor Intensive Care Admission of Newborn LESS LIKELY MORE LIKELY LESS OR SIMILARLY LIKELY

COST EFFECTIVENESS Estimated Annual Cost Savings by Reducing Cesarean Rates to 1995 Level of 22.5 % of NYS Total Births o Avoid unnecessary and non- beneficial interventions o Fewer complications from overuse of medical interventions o Reducing primary and repeat cesareans o Increasing breastfeeding $61 Million Saved by Medicaid

Disparities in Rural Maternity Care ACOG. Health Disparities in Rural Women, Committee Opinion #586, 2014 Enter pregnancy with poorer health status: heart disease, mental illness, cervical cancer, cigarette smoking, alcohol/opioid dependency, obesity Lower income, lack health insurance or use Medicaid, travel longer distances Later entry to prenatal care Higher rates of hospitalization due to complications of pregnancy Higher rates of prematurity, low birth rate and infant mortality Reduced availability of Vaginal Birth After Cesarean Section (VBAC) Reduced access to contraception and reproductive health services

NYS Shortage of Rural Maternity Care Providers 9 counties have no obstetricians 6 counties have no midwives 2 counties have no OBs or midwives Per 100,000 people in NYS, there are 14 obstetricians and 76 NPs/midwives Images used with permission from ACOG for NYSALM

Midwives face so many obstacles that prevent us from working to our full capacities and doing the important work we know we can do. At some point in our careers, every midwife deals with credentialing and licensure issues, roadblocks that impact our ability to obtain hospital privileges, lack of respect for our skills and authority, staffing issues, hospital policies, and insurance restrictions that block us from providing the services women want and deserve... We need the larger community, maternal health care consumers and patients, public health advocates and stakeholders at every level to help us look at things differently so we can better integrate midwives into the greater maternal health system. ~ CHRISTIANE McCLOSKEY, CM, LM BARRIERS TO MIDWIFERY CARE

Right now, midwifery is at the periphery of how we deliver maternal health care in the United States, and it should be in the center of things. We have a huge workforce shortage in maternal health Having systems of care that appropriately take care of the majority of low risk women is definitely the way to go. When you look at it that way, midwives become the obvious solution. NEEL SHAH, MD, MPP, ASSOCIATE PROFESSOR OF OBSTETRICS, GYNECOLOGY AND REPRODUCTIVE BIOLOGY, HARVARD MEDICAL SCHOOL

AUBURN MEMORIAL HOSPITAL 4 midwives, 3 OB/GYNs on staff 73% of Births by Midwives, Midwives attend most vaginal births, across risk spectrum Obstetricians collaborate and focus on cases needing surgical care

Midwifery Leadership in NY State Team-based care, collaboration Patients across risk spectrum Primary care; Reproductive health Advocacy and Committee roles Perinatal Redesignation Maternal Mortality Review, Disparities Opioid Use Disorders Midwifery-Led Birth Center Regulations Maximizing Midwifery to Achieve High- Value Maternity Care in New York, 2018 Buckley, S. Hormonal Physiology of Childbearing: Evidence and Implications for Women, Babies, and Maternity Care. 2015. ACNM BirthTOOLS for LD unit cultural change to promote physiologic birth and reduce primary cesarean sections safely ACNM, Pearls of Wisdom Centering Pregnancy Model

MIDWIVES: High-Value Health Care For Women And Babies In Rural New York EDUCATED WORKFORCE LICENSURE REGULATION PROFESSIONAL PRACTICE Kate T Finn midwifinn@ gmail.com 607-275-7725