HD12 - The Potential for Expansion of the Practice of Nurse Midwives

  • Published: 1992
  • Author: Department of Health Professions and Virginia Health Planning Board
  • Enabling Authority: House Joint Resolution 431 (Regular Session, 1991)

Executive Summary:
House Joint Resolution No. 431 of the 1991 Session of the Virginia General Assembly requested the Virginia Health Planning Board and the Virginia Department of Health Professions to:

• evaluate the potential for expansion of the practice of certified nurse-midwives (CNMs);

• evaluate methods of encouraging family physicians and obstetricians to continue or resume the practice of delivering babies;

• analyze barriers to the practice of nurse-midwifery; and

• determine ways to increase the number of persons interested in nurse-midwifery as a career.

A Task Force was jointly appointed by the Director of the Department of Health Professions and the State Health Commissioner to conduct this review. The Task Force was chaired by a citizen member of the Board of Nursing and included representatives of the Health Planning Board, the American College of Nurse-Midwives (Virginia Chapter), the Medical Society of Virginia, the Virginia Hospital Association, the Organization of Obstetrical/Gynecologic and Neonatal Nurses, and the Virginia Baptist Hospital (Lynchburg).

The Task Force developed this report on the basis of four meetings, a public hearing and analysis of public comments, a review of the relevant policy literature and available data, and the results of a number of national and State policy studies of access to prenatal and obstetric care and of the role of nurse-midwives in extending access to cost-effective, quality care.

House Joint Resolution No. 431 establishes the premise that "access to prenatal care is essential in preventing low birth weight, which is the leading cause of infant mortality," and that nurse-midwives provide quality patient care for a low average cost. Moreover, the Resolution observes that nurse-midwives are prepared to provide prenatal, intrapartum and postpartum care geared to the individual needs of each mother and family and that an increase in the number of nurse-midwives could improve access to care for pregnant women. The Resolution concludes that finding methods of encouraging family physicians and obstetricians to continue or resume the practice of delivering babies, and finding methods of encouraging physicians and nurse-midwives to work together effectively in a collaborative practice would also improve access to prenatal and obstetric care.

Virginia has made great strides in reducing rates of infant mortality and low birth weight over the past decade, but the Commonwealth continues to experience rates above both the national average and the objective set by the U.S. Surgeon General. "Average" rates of infant mortality and low birth weight also obscure unacceptable differences between poor and minority women and those women who can afford and who seek essential prenatal care. Infant mortality and low birth weight rates in rural and inner city areas, and among nonwhite women are often twice the rates of middle-class urban women with adequate insurance.

Certified nurse-midwives are licensed jointly by the Board of Nursing and the Board of Medicine as nurse practitioners in the Commonwealth. As nurse practitioners, nurse-midwives are registered nurses with additional training and experience who practice nursing autonomously at an advanced clinical level and perform other acts which constitute the practice of medicine under the supervision of a collaborating physician. The practice of nurse-midwifery in Virginia is defined as "the independent management of care of essentially normal newborns and women, antepartally, intrapartally, postpartally, and/or gynecologically, occurring within a health care system that provides for medical consultation, collaborative management, or referral."

The competence of nurse-midwives to practice safely and effectively within their scope of practice has been established authoritatively by the U.S. Congress Office of Technology Assessment (1986) and other scientific reviews. The 1986 Congressional review also established that, on average, collaborative practices between physicians and nurse-midwives increase productivity by a factor of 1.5.

There are about 4,000 CNMs in the United States, two percent of whom (76) are licensed and reside in the Commonwealth. This number is disproportionately low given the population of Virginia. A survey of CNMs for the purpose of this review found that one-third of all Virginia CNMs are not engaged in the practice of their chosen profession. The major reasons nurse-midwives expressed for not engaging in nurse-midwifery practice are:

• difficulty in finding collaborating physicians;

• difficulty in obtaining hospital privileges;

• substantial increases in malpractice insurance rates, and;

• lack of direct third-party reimbursement by private insurers.

Despite the obvious need for more adequate prenatal care, the number of obstetricians and of primary care physicians who provide obstetric care has declined drastically over the past decade. A Medical Society of Virginia survey shows that one-third of all physicians who had at one time practiced obstetrics had discontinued that practice by 1989. For family practitioners (excluding obstetricians), the drop-out rate was much worse: only one-quarter of the physicians in this group who had formerly provided obstetric care continued to do so.

The major barriers to continued prenatal and obstetric care expressed by physicians were:

• the high cost of malpractice premiums and fear of malpractice litigation (particularly when serving Medicaid patients and practicing with nurse-midwives);

• low reimbursement rates for Medicaid patients, and;

• "hassles" associated with reimbursement generally.

It is within this context that the Task Force presents its findings and recommendations. The recommendations build on findings of earlier reviews and experiences with previous programs and interventions, and address the following topical issues:

• regulatory barriers to the optimal use of nurse-midwives;

• ensuring a continued supply and appropriate use of nurse-midwives;

• providing incentives for prenatal and obstetric care for the underserved;

• hospital privileges for nurse-midwives;

• ensuring continuity of care;

• building a system for essential prenatal and obstetric care.

Regulatory barriers to the optimal use of nurse-midwives.

The goal of nurse-midwifery is collaborative practice with physicians and not "independent" practice. Collaboration is endorsed as the preferred practice form by the leading national organizations of obstetricians (American College of Obstetricians and Gynecologists) and nurse-midwives (American College of Nurse-Midwives).

Collaborative practice is a regulatory requirement in Virginia. Collaboration can be facilitated under existing statutes and regulations governing the practice of nurse-midwifery, but nurse-midwives and others perceive that these laws and rules are often interpreted narrowly by physicians, hospitals and others to restrict, inhibit, or prevent effective physician/nurse-midwife practice.

The Task Force believes that the Commonwealth should explicitly endorse collaborative physician/nurse-midwife practices. There is also a widely perceived need to differentiate among the scopes of practice of nurse-midwives and other nurse practitioners (primary care nurse practitioners and nurse anesthetists) in regulations promulgated to govern nurse practitioners by the Boards of Medicine and Nursing. This need was recognized in the recent study of access and barriers to the services of nurse practitioners conducted by the Department of Health Professions.

The Task Force endorses the collaborative practice concept of physicians and nurse-midwives emphasized by the American College of Obstetricians and Gynecologists and the American College of Nurse-Midwives.

The Task Force endorses the recommendations of the Department of Health Professions that the Board of Nursing and the Board of Medicine, through the committee of the Joint Boards for the Licensure of Nurse Practitioners, consider the need to define and delineate the scopes of practice of certified nurse-midwives through regulations to be developed and promulgated by the two Boards.

Ensuring the supply and appropriate use of nurse-midwives

There are disproportionately few nurse-midwives practicing in the Commonwealth. While the reasons for this are complex, they include the absence of a nurse-midwifery education program and the lack of familiarity and exposure of Virginia physicians with the competence of nurse-midwives and the cost-effectiveness of collaborative practice.

The Task Force recommends that the General Assembly provide funding and determine the site for an accredited nurse-midwife education program to be established at either or both the health science centers in the Commonwealth -- the Medical College of Virginia/Virginia Commonwealth University or the University of Virginia.

To provide role models for collaborative physician/nurse-midwife practices, the Task Force recommends the joint obstetric practice of certified nurse-midwives, obstetricians and family practitioners in all existing and future medical education programs conducted in the Commonwealth.

Providing incentives for prenatal and obstetric care for the underserved

The cost of one day of preventable care in a neonatal intensive care unit is about $2,000. For this amount, a pregnant woman can be provided essential prenatal and obstetric care. It is thus in the economic interest of the Commonwealth that current disparities in pregnancy outcomes be addressed through incentives for physicians and nurse-midwives to practice in underserved areas and with underserved populations. These incentives include scholarship programs and subsidies to address the costs of malpractice insurance coverage.

Scholarship programs should avoid the pitfalls and problems of earlier educational support programs which prevented these programs from realizing the goal of more even distribution of medical services.

The Task Force recommends that a scholarship program be established for nurse-midwives, initially to provide funding for Virginia residents who are, or will be, in nurse-midwife education programs outside the Commonwealth, then to provide funding for nurse-midwifery students in Virginia educational programs. Recipients of these scholarships should agree to serve in medically underserved areas of the Commonwealth for a minimum time period. Special preference should be given to applicants who currently live in medically underserved areas of Virginia.

The Task Force further recommends that scholarship funding be equivalent to the average annual cost of nurse-midwifery training with the ultimate aim of producing ten certified nurse-midwives each year, with annual adjustments in numbers as needs become more specified.

Finally, with regard to medical and nursing scholarships, the Task Force recommends that current programs be reexamined with the goals of: (a) providing more realistic awards; (b) ensuring future funding to maintain a steady stream of graduates, and (c) ensuring preference for students from rural or other medically underserved areas who agree to return to serve in these areas. Existing and future scholarship programs should build carefully on the experience developed with scholarship programs over the past two decades.

Subsidization of malpractice insurance coverage should occur only after the Commonwealth is convinced that premiums and premium surcharges for the obstetric practices of physicians, nurse-midwives, and collaborative physician/nurse-midwife practices are equitable and actuarially sound. There is evidence that premiums do not reflect actual malpractice experience.

The Task Force recommends that the Commission on Health Care for all Virginians study the actuarial basis for the cost of malpractice insurance for obstetricians and for other physicians who offer obstetric services, for certified nurse-midwives, and for collaborative obstetric services involving physicians and nurse-midwives who provide care for Medicaid and indigent patients and for others in medically underserved areas of the Commonwealth.

The Task Force recommends further that the General Assembly provide for annual actuarial studies of the Birth-Related Neurological Injury Compensation Act and for premiums to be set consistent with actuarial experience.

Contingent upon the outcome of these reviews, the Task Farce recommends that the General Assembly consider a plan to subsidize malpractice insurance premiums for physicians and nurse-midwives who provide prenatal and obstetric services to Medicaid, medically indigent, or other women in medically underserved areas of the Commonwealth. Such subsidies could consist of direct payments or increases in Medicaid reimbursement of providers of obstetric services who meet conditions of participation.

Other incentives should also be considered. While the competence and cost-effectiveness of collaborative nurse-midwife/physician practice is firmly established, the health care enterprise is slow to integrate nurse-midwives into the mainstream of prenatal and obstetric care. "Most favored" status may be necessary to stimulate change.

The Task Force recommends that appropriate State agencies develop financial incentives for health care practitioners, hospitals, and local health departments who agree to work with certified nurse-midwives to provide perinatal services in medically underserved areas or for medically underserved populations.

The Task Force recommends that the Department of Medical Assistance Services consider providing reimbursement for the ancillary services (e.g., family planning, nutritional counseling) provided by nurse-midwives to Medicaid recipients. In addition, it is recommended that the Department review the possibility of providing incentive payments for prenatal and obstetric services to Medicaid recipients provided by collaborative physician/nurse-midwife practices.

Hospital privileges for nurse-midwives

Nurse midwives maintain that difficulties in securing hospital privileges remains a major obstacle to their fuller utilization in the communities in which they live and work. While it would appear that current regulatory and accreditation standards, as well as existing hospital bylaws and policies do not prohibit the granting of privileges to nurse-midwives, some evidence exists of resistance to the granting of these privileges. Again, it may be necessary to provide protective legislation to prevent exclusion of nurse-midwives for any but legitimate reasons. A precedent for such legislation exists in current statutes preventing the exclusion of podiatrists from hospital staff privileges (see Code of Virginia Sec. 32.1-114.1 et seq.).

The Task Force recommends that the Commission on Health Care for all Virginians initiate and support legislative proposals to amend open staff provisions of current hospital licensing statutes to include certified nurse-midwives whose collaborating physicians have privileges.

Ensuring continuity of care

The Task Force heard repeated evidence of pregnant women arriving at hospital emergency rooms for delivery or other maternal health care with no coordination of these services with prenatal services provided by health department clinics or private practitioners. These practices are dangerous and costly to hospitals, particularly for those women who have no health insurance or benefits.

The Task Force recommends that health departments that provide antepartum care be required to make appropriate arrangements to ensure linkage with delivery and postpartum care services. As part of this arrangement, the patient's medical records should be readily available to the involved health care providers (e.g., through computer linkages or hard copy transfer).

Ensuring a system for essential prenatal and obstetric care.

While subsidy of malpractice insurance, provision of hospital privileges for nurse-midwives, establishment of educational programs to produce more nurse-midwives, and creation of scholarship programs to recruit new members of the nurse-midwifery profession can contribute to a better match between prenatal and obstetric needs and resource, these interventions alone cannot ensure a balance of needs and resources at the local level.

To meet the demand for essential care throughout the Commonwealth, policymakers must focus their efforts on developing systems of collaboration and support among providers, consumers and payers in each community so that local leaders may effectively coordinate services to meet community needs.

The Task Force found evidence of effective local collaboration and coordination in a number of innovative models in Virginia and elsewhere. These local models incorporate the philosophy that maternal care is an essential public service, analogous to public utilities and fire and police protection, a concept that enjoys wide acceptance in other industrial and post-industrial societies. The philosophy is based on recognition of the fundamental value of human capital, as well as upon simple economics.

The roles of the State and of local health departments are critical to the ultimate success of any community models for collaboration and coordination of maternal care. The State must provide leadership, encouragement and support and stand ready to fund any shortfall between the limits of community resources and the totality of community need. The community must provide both a commitment to the goal of universal, cost-effective, quality care and a nexus for coordination of the concerns of local health department representatives, hospital officials, family practitioners, obstetricians , certified nurse-midwives, and citizens.

The Task Force recommends that the General Assembly mandate and fund local health departments to arrange for the provision of essential prenatal care for their patients with local options for providing such care.

The Task Force endorses the concept of perinatal regional care practiced in a manner systematically related to the essential perinatal care needs of individual communities and the regions. To assess local needs and priorities and to develop strategies to meet these needs at a local level, community advisory panels should be developed (and existing panels expanded) to include local health department representatives, hospital officials, family practitioners, obstetricians, certified nurse-midwives, and citizen members.

Finally, the Task Force wishes to recognize the existence and growth of the phenomenon of "birthing centers" as an innovation worthy of exploration in the Commonwealth.

Birthing centers are facilities that may or may not be administered by hospitals but are separate from them, as well as facilities that are attached administratively and physically to hospitals. These centers provide delivery services to low-risk women in home-like settings. Typically headed and staffed by certified nurse-midwives, birthing centers were developed as a socially warmer, lower-cost alternative to traditional hospitals.

The first free-standing facilities were established to serve medically underserved , rural communities. The birthing center movement has spread to urban centers and to the provision of services to economically advantaged women who prefer both the environment and the nurse-midwife as primary caregiver. A number of studies indicate that birthing centers are safe and cost-effective. Some states now regulate these centers, and a program of private accreditation has been developed.

The Task Force recommends that the Virginia Health Planning Board study the efficacy of birthing centers in extending access to obstetric care. The study should include exploration of other states' experiences (e.g. Florida, North Carolina, Tennessee, and California) and of their regulatory requirements.

The Task Force appreciates this opportunity to be of service to the government and the people of Virginia.