Nurse-Midwives In Georgia - Georgia State Senate

Nurse-Midwives in Georgia:Value for Georgia CitizensNicole S. Carlson PhD, CNMPresident, Georgia Affiliate ofAmerican College of Nurse-MidwivesAssistant ProfessorEmory University School of Nursing

Birth in GeorgiaGeorgia Births in 2013:128,748One of nation’s highestWomen in GA atincreased risk for: MaternalPregnancyRelated Mortality Infant Mortality Prematuredelivery CesareandeliveryKaiser Family Foundation, 2015

Maternity Care Workforce

Current Maternity Care Providers in the USOB/GYNs Medical degree &specialized residency Skilled in specializedsurgical techniques andprimary care Trained to attend low,moderate and high riskbirths and addresscomplications and comorbidities 99.9% of births theyattend occur in hospitals.Certified NurseMidwife Masters Degree Skilled in normal birth forwomen with lowmoderate risk Provide primary care towomen of all ages 94.6% of the births theyattend occur in hospitals.CertifiedProfessionalMidwife Most complete a nonaccreditedapprenticeship model ofeducation Care for women of lowrisk Do NOT provide primarycare 16.9% of births theyattend occur in hospitals

Ideal Maternity Care Workforce Structure

Current US Workforce StructurePhysicians are themost commonmaternity careprovider in the US.45,00043,732Number of Providers40,00035,00030,00025,00020,000Percent of 2013 U.S. BirthsPhysicians:90.4%Nurse-Midwives: 8.2%Other urces in Notes View.CNMs/CMsCPMs

Inter-Professional Collaboration – The LedCare“Ob-gyns and CNMs/CMs are experts in their respective fields of practice and are educated, trained, andlicensed, independent providers who may collaborate with each other based on the needs of their patients.Quality of care is enhanced by collegial relationships characterized by mutual respect and trust, as well asprofessional responsibility and accountability.”Joint Statement of Practice Relations Between Obstetrician/Gynecologists and Certified Nurse-Midwives/Certified MidwivesSources in Notes View.

Percent of Births Attended by CNMs - .48%ND6.13%VT 37%MO3.31%KY5.95%TN 14.02%Source: CDC Vital Stats, Births - Available at:http://www.cdc.gov/nchs/data access/vitalstats/vitalstats births.htmNH 18.95%MA 15.22%RI 11.13%CT 11.01%NJ 6.90%DE 8.77%MD 9.74%DC 10.72%0% – 4.50% of births4.51% – 6.49% of birthsLA2.62%6.50% - 8.89% of birthsFL10.41%HI 8.81%ME17.78%8.90% - 11.99% of births12.00% - 28.00% of births

Obstetricians by GACounty48% of GA countiesdo not have anobstetricianOf those countieswith anyobstetrician, 22%have only one

Certified NurseMidwives by GA County53% of GA counties donot have a CertifiedNurse Midwife501 CNMscurrentlylicensed inGA(Nov, 2015)Of those counties that dohave Certified NurseMidwife presence, 31%have only one

South Georgia Sparcity of CNMsOB-GYNs in GeorgiaCNMs in Georgia

Where do GA CNMs work?Place of EmploymentNumber of GA CNMsHospital173Ambulatory clinic69Public Health8Insurance claims/benefits2Nursing Home/Extended Care2Home Health9Academic33Correctional facility1School health service2Other68Community health16TOTAL38332% of CNM licensed in GAdo not provide prenatal orbirth care.Source: GA APRN Leadership Taskforce Survey, 2015

Where do GA CNMs work?Place of EmploymentNumber of GA CNMsHospital173Ambulatory clinic69Public Health8Insurance claims/benefits2Nursing Home/Extended Care2Home Health9Academic33Correctional facility1School health service2Other68Community health16TOTAL383Reasons cited by CNMs fornot providing midwiferycare: Difficulty finding jobs Difficulty finding physiciancollaborators Difficulty getting hospitalprivilegesMany student CNMseducated in GA leave thestate for the same reasons.Source: GA APRN Leadership Taskforce Survey, 2015

Savings in Care by CertifiedNurse Midwives

Average Total Charges and Payments forMaternal and Newborn Care in the U.S. - 2010 60,000 10,000 13,590 50,373 9,131 29,800 20,000 18,329 30,000 32,093 40,000 27,866 51,125 50,000The gap between costsand reimbursement putsgreat strain on healthcaresystems 0Commercial - Commercial VaginalCesareanChargesSources in Notes View.Medicaid VaginalMedicaid CesareanCesarean birth results inlarger financial losses forthe hospital andproviders, especially forMedicaid patients

Savings From the Midwifery Model – Cesarean SectionsHypothetical Group of 1,000 WomenNumber of WomenGiving Birth viaCesarean SectionPayments for All 1,000Births if All Covered byMedicaidPayments for All 1,000Births if All Covered byCommercialCNM AttendedWomen(8.5% cesarean rate)85 9,837,106 19,797,863Physician AttendedWomen(14.7% cesarean rate)147 10,122,014 20,407,230ReducedCesareans/Savingsfrom MidwiferyModel62 284,908 609,367Description of methodology in “Notes” view.

What Can Policymakers Do to AccessSavings through the Midwifery Model?

Full PracticeAuthorityRegulatory Structure forCertified Nurse-Midwives and Certified MidwivesData Current as of June KSCAMOVAKYOKNMARSCMSALGASupervision RequiredTXWritten CollaborativeAgreementLAFLAKHIDCNCTNAZNJDEINCOMACT RIWritten CollaborativeAgreement --- Rx OnlyIndependent PracticeLegally required supervisory or collaborative business relationships are not the same thing as normal collegialprovider relationships that result in consultation, collaboration and referral. Inability to find a physician who willenter into such a business relationship often limits where midwives can practice and what they can do.Source: ACNM analysis of state laws and regulations.

HospitalPrivileges andMedical StaffParticipationMedical Staff Provisionsfor Certified Nurse-Midwives in Law and RuleData Current as of January KSCAMOVAKYOKNMDCNCTNAZNJDEINCOMACT RIARSCMSALGAMembership is DeniedNote: Could be Implicit orExplicit DenialTXLAFLMembership is AllowedNote: Could be Implicit orExplicit AllowanceAKHINearly 95% of CNM attended births occur in a hospital. Hospitals are often allowed, but not required to extendstaff membership to CNMs on the same footing as they do physicians. Not being on staff means they can’t helpformulate or vote on policies that directly impact their ability to uphold the midwifery model.Source: ACNM analysis of state laws and regulations.

SupportMidwifery/Physician CollaborationAthens Regional MedicalCenter Midwives Practice started 1976 toprovide accessible, highquality care and delivery forwomen using Medicaid inAthens/Clarke county. Now: CNMs at ARMC travel toGreene, Barrow, and Bankscounties every week toprovide prenatal care. Plans to expand model toMorgan and Elbert counties Women come to AthensRegional:– for labor with a CNM– For ultrasounds– For high-risk consultation orcesarean with physician

Athens Regional Midwifery ServiceClarke CountyPretermBirth RateInfantMortality13%6/1,000 livebirthsAthens Regional 6-7%Midwifery Service3/1,000 livebirthsClaude Burnett, MD, MPH, Director ofthe North East GA Health District:“The infant mortality rate in theAthens District has steadily declinedover the past 30 years, partially dueto the services and standard of careprovided by the Athens RegionalNurse-Midwifery Practice.

Perinatologist atRegional MedicalCenter provides:Georgia Rural Maternity Care Model High-risk consultation(tele-health, in person) AntepartumhospitalizationPhysician Hospitalistprovides: Cesarean delivery Consultation withmidwives Higher-risk antepartumvisits UltrasoundsNurse-Midwives from ruralcounty clinics rotate toprovide normal Labor &Delivery CareNurse-Midwives care for women within counties

Next Steps for Georgia to Increase Use of NurseMidwivesFull PracticeAuthorityHospitalPrivileges andMedical StaffParticipationSupportMidwifery/Physician CollaborationFund Educationof NurseMidwives in GA Ensure that applicable laws and regulations allow CNMs tofreely utilize the full extent of their education and training. Ensure that hospitals provide CNMs with privileges andinclude them on medical staff. Support the formation of CNM-OB partnerships to provideappropriate care for all women by risk status Expand GA’s Preceptor Tax Incentive Program to coverNurse-midwife preceptors Expansion of GA’s Rural Physician Tax Credit & Physicians forRural Areas Assistance Program to cover nurse-midwives

Nurse-Midwifery for Georgia Excellent outcomesfor women & families Evidence-based Formally educated Primary care Partnership Valuewww.georgiamidwife.org

Thank you

Midwifery Care Reduces Cesareans Prospective study at community hospital in SanFrancisco 2005-2014 Hospital change for labor management in 2011:– Old model: Several obstetricians care for women in labor– New model: Several Nurse-Midwives care for women inlabor with single Obstetrician as backup Decreased rate of cesarean delivery following change:– 5% first year– 2% each year thereafter (32.2% to 25.0% in 9 yrs)– Highly statistically significant changeRosenstein et al, 2015. The effect of expanded midwifery and hospitalist services on primarycesarean delivery rates. American Journal of Obstetrics & Gynecology

Physician careCNM careThe majority of maternal and newborn careideally provided by a midwife in this framework ofquality maternal/newborn care

Nurse-Midwives in Georgia: Value for Georgia Citizens Nicole S. Carlson PhD, CNM President, Georgia Affiliate of American College of Nurse-Midwives Assistant Professor Emory University School of Nursing . Birth in Georgia Georgia Births in 2013: . for Certified Nurse-Midwives in Law and Rule Data Current as of January 2014 MT WY MI ID .