The Role of Certified Nurse-Midwives and

Certified Midwives in Ensuring Women’s

Access to Skilled Maternity Care

November 2015
Jesse S. Bushman
Director, Advocacy and Government Affairs
American College of Nurse-Midwives
 Presentation Purpose
• Describe current trends in the maternity
care workforce
• Describe the role of CNMs/CMs in
addressing maternity care provider
shortages
• Put forward specific proposals to address
barriers to educating more CNMs/CMs
 Defining Terms – CNMs, CMs and CPMs
Unless specifically noted, this presentation focuses on the practice of Certified Nurse-Midwives
(CNMs) and Certified 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 certification examination administered
by the American Midwifery Certification 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 certification 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.
• Certified 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.
Patient Needs
 Projected Numbers of Women, 2015-2060
190,000,000

170,000,000

150,000,000

130,000,000
Nearly 44 million more women (12 million Age 15+
of childbearing age) will need care in 2060.
110,000,000 Age 15-49

90,000,000

70,000,000

50,000,000
1 4 1 7 2 0 2 3 2 6 2 9 3 2 3 5 3 8 4 1 4 4 4 7 5 0 5 3 5 6 5 9
20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20

Sources in Notes View.

 Projected Births in the United States – 2014-2060
5,000,000

4,800,000

4,600,000

4,400,000

4,200,000

4,000,000

3,800,000
The Census Bureau estimates a 14% increase in the
3,600,000 number of births per year by the end of this timeframe.

3,400,000

3,200,000

3,000,000
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.
Pregnancy and Newborn Care Hospital Discharges Together Far
Outnumber Discharges for any Other Major Diagnostic Category

Circulatory System 4,796,175

Pregnancy, Childbirth 4,160,286

Newborns & Other Neonates 3,933,511

Respiratory System 3,549,166

Musculoskeletal System & Conn Tissue 3,251,134

Digestive System 3,242,725

Nervous System 2,192,941

Kidney & Urinary Tract 1,671,380

Mental 1,428,060

Infectious & Parasitic Diseases 1,428,045

0 500,000 1,000,000 1,500,000 2,000,000 2,500,000 3,000,000 3,500,000 4,000,000 4,500,000 5,000,000

Number of Discharges

Sources in Notes View.

Workforce Demographics
P r o v id e r s p e r 1 0 ,0 0 0 W o m e n

Maternity Care Providers per 10,000 Women Age 15-49 Years

• Many providers are not clinically active.

• As the population ages, a larger portion of clinician time will
be taken up rendering primary care to older women.

10.00
9.00
8.00
7.00
6.00
5.00
4.00
3.00
2.00
1.00
0.00

2013

2015
2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

2014
OB/GYNs CNMs/CMs Total

Sources in Notes View.

P r o v id e r s p e r 1 0 ,0 0 0 W o m e n

Maternity Care Providers per 10,000 Women Age 15+ Years

The ratio has not changed appreciably in 16 years.

10.00
9.00
8.00
7.00
6.00
5.00
4.00
3.00
2.00
1.00
0.00

2013
2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

2014

2015
OB/GYNs CNMs/CMs Total

Sources in Notes View.

 First-Year OB/GYN Residents and Newly Certified CNMs/CMs, 1979 - 2014
2,000
1,800 • The number of medical graduates entering OB/GYN
residencies has remained relatively flat for three decades.
1,600
• New CNMs/CMs have been increasing recently.
1,400
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 Certified CNMs/CMs

Sources in Notes View.

 Distribution of OB/GYNs by Age
50%
• More than 15,000
45% OB/GYNs will likely
40% retire in the next
35% decade, outpacing the
rate of new OB/GYNs
30% entering the profession
25% by 20%.
•

31.20%
In 2013, 82.6% of first
29.80%

20%
26.90%

25.30%
24.70%

year OB/GYN residents

5.20%

20.10%
15%
16.60%

3.40%
and interns were

11.80%
10% women.
5% • Over time, the OB/GYN
profession will become
0%
<35 Yrs 35-44 Yrs 45-54 Yrs 55-64 Yrs 65+ Yrs predominantly female.

Age
Males Females

Sources in Notes View.

 Multiple Studies Show Female Physicians Work
Fewer Hours than Male Physicians
Average Hours Worked per Week, 2005-2007

A 2006 AAMC survey found that

among physicians who had the
option to work part time, 34% of
female physicians did so, while
only 7% of male physicians did.

Age

Sources in Notes View.

 Average Age at which ACOG Fellows
Stop Practicing Obstetrics
Age (years)

55

51
50

45

42

51.9
51.7
40 51.2
50.2

Males
48.4

43.8
Females

43.1
35 40.8
39.5

39.2

30

25
1992 1996 1999 2003 2006 2009

Year of Study

Sources in Notes View.

 An Increasing Percent of OB/GYNs are Subspecializing

Reproductive
Gynecologic Endocrinology
Oncology and Infertility

In 2000 7% of OB/GYN residents

Obstetrics/ entered a subspecialty
fellowship. In 2012, 19.5%
Gynecology subspecialized. Many OB/GYN
Maternal- subspecialists do not typically
Fetal attend births.
Medicine
Female Pelvic
Medicine and
Reconstructive
Surgery

Sources in Notes View.

 Bottom Line: Serious Challenges

Serious
challenges with
ensuring skilled
attendants
at birth
Static entries into Changes in provider Increasing patient
OB/GYN residencies demographics needs
and increasing
subspecialization

Using a measure of demand that takes into account population, prevalence and
incidence of conditions and disease, as well as rates of insurance coverage, available
supply of providers and utilization of care, ACOG has projected a shortage of between
15,723 – 21,723 OB/GYNs by 2050.

Sources in Notes View.

Workforce Maldistribution
Compounding the Problem
 Obstetrician/Gynecologists per 100,000 Population
Data Current as of 2011

ACOG estimates
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. Counties, 1,459 (46%) have no OB/GYN.

Sources in Notes View.

 Certified Nurse-Midwives per 100,000 Population
Data Current as of 2011

CNMs per 100,000

0

0.1 – 4.9

5.0 +

Out of 3,142 U.S. Counties, 1,758 (56%) have no CNM.

Sources in Notes View.

 CNMs and OB/GYNs per 100,000 Population
Data Current as of 2011

CNMs & OB/GYNs

per 100,000
0

0.1 – 29.9

30.0 +

Out of 3,142 U.S. Counties, 1,263 (40%) have no CNM or OB.

Sources in Notes View.

Patient Population
vs.
Workforce Structure
 Pregnancy and Risk Stratification
There is no uniformly utilized definition of a high risk
pregnancy.
• CDC estimates that in 2013, 83% of first time
Highe
r mothers were at low risk for a cesarean birth.1
Risk • The NIH lists several high risk factors affecting 2-
Pregn 10% of pregnancies.2
ancies • More than half of pregnant women in the US are
overweight or obese, which increases their risk.3

Low-Moderate
Risk It is reasonable to assume that the majority
of women are low-moderate risk.
Pregnancies

Sources in Notes View.

Ideal Maternity Care Workforce
Structure

Ideally, the workforce Provide

Highe
r structure reflects the rs
Risk makeup of the patient Trained
to
Pregn population
Treat
ancies Higher
Risk

Low-Moderate Providers
Risk Trained to Care for
Women with Low-
Pregnancies Moderate Risk
 Current Maternity Care Providers in the US

OB/GYNs CNMs/CMs CPMs

• Medical degree & • Masters Degree • Most complete a non-
specialized residency • Skilled in fostering accredited
• Skilled in specialized innate, hormonally apprenticeship model of
surgical techniques and driven processes of education
primary care normal physiologic birth • Skilled in fostering
• Trained to attend low, for women with low- innate, hormonally
moderate and high risk moderate risk driven processes of
births and address • Provide primary care to normal physiologic birth
complications and co- women throughout the for women of low risk
morbidities lifecycle • Do NOT provide primary
• 99.9% of births they • 94.6% of the births they care
attend occur in hospitals. attend occur in hospitals. • 16.9% of births they
attend occur in hospitals

Both physicians and midwives are essential to an

appropriately structured maternity care workforce.
 CNMs/CMs are Appropriate Providers for Low-Moderate Risk Pregnancy
• The Lancet - 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 the composition, development,
and distribution of the health workforce in all countries.”
• Cochrane Reviews – 2013 and 2009
“The review concludes that most women should be offered midwife-led
continuity models of care, although caution should be exercised in applying
this advice to women with substantial medical or obstetric complications.”
• Women’s Health Issues - 2012
“Based on this systematic review, there is moderate to high evidence that
CNMs rely less on technology during labor and delivery than do physicians
and achieve similar or better outcomes.”
Note that these studies look at midwives meeting standards of the
International Confederation of Midwives. CNMs/CMs meet or exceed
such standards. It is not clear at this point whether or how many CPMs
Sources in Notes View. in the US meet such standards.
 Inter-Professional Collaboration – The Ideal

Lower Higher
Moderate
Risk Risk
Risk
Patients Patients
Patients

Midwife-Led Jointly-Led Physician-Led

Care Care Care
“Ob-gyns and CNMs/CMs are experts in their respective fields of practice and are educated, trained, and
licensed, 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 as
professional responsibility and accountability.”
Joint Statement of Practice Relations Between Obstetrician/Gynecologists and Certified Nurse-Midwives/Certified Midwives

Sources in Notes View.

 Current US Maternal Care Workforce Structure

Providers Trained to
Treat Higher Risk Higher
(43,732 OB/GYN Risk
Fellows/Jr. Fellows*) Pregnanci
es
(1,500,000
births*)

Providers trained to care

for women with normal The US
Normal
Pregnancies (11,113
CNMs/
CMs and
maternity care Pregnancies
1,800 workforce is
CPMs*)
upside down (2.4 million births**)
relative to
patient needs.

Sources in Notes View

 How We Got Upside Down:
Public Investment in Developing the Maternity Care Workforce
• Medicare policies say nothing with
$14,000,000,000
regard to whether CNMs/CMs can
$12,000,000,000 be paid for supervising medical
$15,000,000,000

interns, residents or student

$10,000,000,000 midwives.
$8,000,000,000
• Teaching physicians are
reimbursed for services of medical
$283,000,000

$6,000,000,000 interns/residents under their

$224,000,000

$50,000,000

$4,000,000,000
supervision.
• While there may be midwives in
$2,000,000,000 teaching hospitals who are willing
$0
to precept CNM/CM students,
2014 Expenditures these hospitals have a powerful
Graduate Medical Education
National Health Service Corps
economic incentive to favor
Nursing Workforce Development (Title VIII of the PHSA) education of OB/GYN residents.
Graduate Nursing Education Demonstration

Sources in Notes View.

 How We Got Upside Down:
Public Investment in Developing the Maternity Care Workforce
6,000 • Medicare GME funds approximately
73% of medical residents. Others may
5,000
be funded through Medicaid, the VA or
4,000 commercial GME.
3,670 Total GME spending amounts to approximately
3,000 $127,000 per year for every resident in the U.S.
4 Spending on each OB/GYN resident is reportedly
$100,000/year
2,000
2,395 • The GNE demonstration funded
1,000 1,358 approximately 0.17% of CNM/CM
students (available in only one
0 educational program)
OB/GYN CNN/CM Total GNE spending on CNM/CM preceptor sites
Residents Students
is approximately $25 per year for every CNM/CM
2014
student in the U.S.
Supported through GNE or GME
Not supported Through GME or GNE

Sources and methods in Notes View.

 How We Got Upside Down:
Individual R ecipients

The National Health Service Corps

3,000 NHSC Funding goes to

2,500 individuals in the form
of scholarships or loan
2,000 repayment, it does
2,873

not reward clinical

2,405

1,500
preceptors.
1,000
157
130

500
51
40

0
Physicians Working Off a Multi-Year Commitment for Past Award
NPs/PAs/CNMs Working off Multi-Year Commitment for Past Award
OB/GYNs Working Off a Multi-Year Commitment for Past Award
CNMs Working off Multi-Year Commitment for Past Award
OB/GYN Recipients - 2014
CNM Recipients - 2014

Sources in Notes View.

 Maternal Care Workforce Structure in Several Developed Countries:
Midwives per Obstetrician
20.00
15.67

18.00 • Other developed countries have structured their maternity

16.00 care workforce to match the needs of their population.
• The midwife-to-obstetrician ratio in the US is one-eighth the
14.00
median among this group.
9.67

12.00
19.49

10.00
6.54

8.00
4.52

4.39

3.94

3.83

6.00 3.23

2.57

2.54

1.94
4.00

1.57

1.21

1.06

1.00

0.87

0.83

0.40

0.32
2.00
0.00
s l
UK ralia ium land nce ark den any pan nd tria rea uga Italy ece pain urg ore ada US
st el
g
Fi
n a
F r e n m Sw e e r m Ja rla
e A us Ko ort Gre S bo gap Can
u B P m in
A D G
e th x e S
N Lu

Sources listed in Notes View.

 Maximizing Midwifery: What is Possible
100% 4 4 4 5 9 28
Maternal mortality
90%
2 2 2 3 3 6 per 100,000 live
80% births (2013)
70%

60%

50% Infant mortality

78%

77%

75%

-probability of
72%

72%
40%
dying by age 1 per
30%
1,000 live births
(2012)

9%
20%

10%

0%
Finland Iceland Sweden Denmark France US

Percent of Births Attended by Midwives

Sources in Notes View.

 Reasonable Expansion of Midwifery in the US Context
100% • Among the five states with the
highest percentage of • If CNMs/CM/CPMs had
90%
CNM/CM/CPM attended births in attended 24% of all 2013
80%
2013 the average was 24%. births, they would have
70% • Nationwide, in 2013,
attended 594,300 additional
CNMs/CMs/CPMs attended 8.9%
60%
of all births. births.
50% • Expansion of midwifery across
40% the country to reflect what is
30%
already occurring in these five
states would greatly alleviate
30.7%

26.3%

22.3%

20%
20.8%

19.8%
current pressures on the
10%
OB/GYN workforce.
0% • Such expansion in the US is a
Alaska New Vermont New Oregon
Mexico Hampshire reasonable goal.
Percent of Births Attended by CNMs/CMs/CPMs

Sources in Notes View.

 Physician Time as an Economic Asset

Using OB/GYNs to attend most normal births

Educating OB/GYNs entails
underutilizes the economic value of their full
enormous public and personal
skillset and results in a less than optimal return on
investment
their personal investment and that of the public
 Physician Time as an Economic Asset

When OB/GYNs focus on higher

MGMA studies show physician groups that use
risk mothers, they more fully
nurse practitioners are more economically
utilize their skillset, maximizing
healthy and physicians experience higher
the return on personal and
compensation because they focus on providing
public investment in their
services that only they can render.
education.

Sources in Notes View.

 Cost and Length of Education:
CNMs/CMs as an Answer to the Maternity Care Provider Shortage
Years to Complete Education Total Cost of Education
$250,000
8
7 Educating $200,000
4
6 midwives is
5
comparatively $150,000
rapid and

208138
4
economical. $100,000

$131,556
3
4 0
2

$53,505
$50,000
2
1
0 $0
OB/GYNs CNMs/CMs Medical School CNM/CM
Education
Residency
Public Institution Private Institution
Medical School or Midwifery School
Average of Public and Private Institution Costs
• 13 of the 39 midwifery education programs offer a 2-year MS or
the option of a 3-year DNP program.
• Many midwifery programs require 1-year of experience as an Note that physicians will likely incur additional expenses
RN prior to acceptance into the program. during their residency.

Sources in Notes View.

 Precepting Students: The Most Significant Challenge to
Creating More CNMs/CMs

• Preceptors are CNMs/CMs who

• Precepting students
oversee students and help them
reduces the instructor’s
experience the hands on,
revenue generation and/or
specialized caregiving associated
increases work hours.
with the midwifery model.
• CNM/CM education
• A large percentage of preceptors
programs consistently
are active community clinicians,
report that obtaining
rather than faculty who work in an
sufficient preceptors is the
educational institution and
primary barrier to
dedicate their time solely to
educating more CNMs/CMs.
instruction.

Sources in Notes View.

 Precepting Students: The Most Significant Challenge to
Creating More CNMs/CMs
Most CNM/CM Preceptors
Are Unpaid
100%
90% • The GNE demonstration is reimbursing
CNM preceptors with $15,000/year per
80%
student.
70% • CNM/CM students need precepting
60% during approximately 80% of their two
50% year program.
• Based on GNE expenditures, $24,000 is
40%
62%

an appropriate amount needed to

30% precept a student throughout their
38%

20% entire education.

10%
0% Unpaid Midwifery Preceptors
Paid Midwifery Preceptors

Sources in Notes View.

 Funding for Maternity Care Workforce
Development
What would the public get for an investment of $10 million in
developing the maternity care workforce?
GME or Number of Average number Additional births that could
precepting costs practitioners of births attended be attended annually by the
per practitioner to that could be annually by a additional skilled
complete their supported with single practitioner practitioners educated as a
residency or $10 million result of the $10 million
education investment

Physicians $400,000 25 122* 3,050

CNMs/CMs $24,000 417 70** 29,190

Sources and methods in Notes View.

 Supporting Midwifery Education: The ROI

Savings from Reduced Rates of Cesarean Birth

Rate of cesarean 2015 costs for using this Medicaid portion Commercial
birth among low- provider type to attend of these costs portion of these
risk women.* 70 low-risk women.** costs

Physicians 14.66% $1,113,884 $309,636 $804,248

CNMs/CMs 8.49% $1,081,191 $300,931 $780,260

• One year ROI for the average Medicaid program is $8,705. During that same period,
commercial payers would save $23,988. These savings would accrue from reductions in
cesarean births alone.
• Further savings from the midwifery model would accrue based on other aspects of their
practice (e.g., reduced use of epidurals).

Sources and methodology in Notes View.

What Can be Done to Increase the
Supply of CNMs/CMs?
 Potential Solutions
• Identify Shortage Areas
• Funding for the NHSC
• Graduate Nurse Education Program
• Tax credits for preceptors
• Payment for supervised services
• Revisions to medical school OB rotations
 Getting More Data: H.R. 1209/S. 628
“Improving Access to Maternity Care Act of 2015”

• HRSA to designate maternity care

health professional shortage areas –
locations or populations without
sufficient full scope maternity care
providers or hospitals or birth center
labor and delivery units.
• NHSC scholarships and loans could be
available to maternity care providers
who agree to work in these new
shortage areas.
 Potential Solutions: Helping Midwifery Students
National Health Service Corps Expenditures

$900,000,000

$800,000,000 • HRSA’s proposed FY 2016 budget

$700,000,000
would increase the NHSC field
strength by 6,664.
$287,370,000

$600,000,000
• NHSC helps students afford their
$810,000,000

$500,000,000 education, but does not address

$400,000,000 the challenges with obtaining
$300,000,000
more preceptor sites.
$200,000,000

$100,000,000

$0
FY 2015 Appropriation
FY 2016 Presidential Budget

Sources in Notes View.

 Potential Solutions:
The Graduate Nurse Education Demonstration

$200 Million
Hospitals partner with
given to 5 …to provide
schools of nursing and clinical education
hospitals community clinical sites… for more advanced
over 4 years practice nurses.

Sources in Notes View.

 Potential Solutions:
Georgia Preceptor Tax Incentive Program
Certain medical,
NP and PA
students.
Each 160 $1,000 Tax
Hours. Deduction.

480 hours of
Maximum deduction = $10,000
precepting to
qualify.

Sources in Notes View.

 Potential Solutions:
Reimbursing Midwife Educators

CNMs/CMs frequently provide

Medicare pays teaching
physicians for the services of
the interns/residents that
they are educating.
educational 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
education or supporting
midwifery education.

Legislation 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.

 Changes to Medical Education
• Have medical students get exposure to obstetrics
through mechanisms other than direct patient
care allowing student midwives that opportunity
instead.
• Modifying OB/GYN residency requirements for
those who plan to subspecialize in areas that do
not involve attending births so that student
midwives can have those clinical experiences
instead.
Appendix
 Data from Risk Adjusted Comparative Studies in the US: % of Cesarean Births

34.00%
Among studies reporting study population and incidence
figures, there were 2,435 cesareans among 19,241 births
attended by physicians (12.66%) and 304 of 3,746 births
30% attended by Midwives (8.12%). Among all studies the
averages of the respective rates are 14.66% and 8.49%
25%

20%

25.80%
15%

19.30%

19.10%
18.07%

16.60%
15.90%

15.60%
4.00%

13.70%
13.60%
13.00%

13.00%
12.88%

12.73%

12.40%
12.30%

10%

2.44%
10.70%
2.14%

2.00%

1.93%
9.75%

8.80%
8.51%
0.40%

8.40%

7.93%
6.67%

5.60%
5%

0%
Study Study Study Study Study Study Study Study Study Study Study Study Study Study Study
1- 2- 3- 4- 4- 4- 5- 6- 7- 7- 8- 9- 9- 10 - 11 -
-5% 1992 1993 1993 1994 1994* 1994* 1995 1997 2002 2002* 2003 2006* 2006 2013 2015

Physician Attended Births Midwife Attended Births

Sources and methods listed in “Notes” view. Among the 234 midwifery practices reporting on
* Study 4 included overall cesarean rates, as well as C/S for primiparas and multiparas cesarean. 97,158 births in ACNM’s 2013 benchmarking data,
* Study 7 included overall cesarean rate and primary cesarean rate. the median rate of cesarean birth was 11.8%
* Study 9 included overall cesarean rate and primary cesarean rate.
 Average Total Charges and Payments for
Maternal and Newborn Care in the U.S. - 2010

$60,000 Inflating these figures

by the Medicare
$50,000 Economic Index (MEI)
yields an estimate that
$40,000 in 2015 dollars
commercial insurers
$51,125

$50,373
are incurring costs of

$13,590
$30,000
$18,961 for vaginal
$32,093

$9,131
$29,800
births and $28,826 for
$27,866
$20,000 cesarean births, while
$18,329

Medicaid programs are

$10,000 paying $9,446 and
$14,058 respectively.
$0
Commercial - Commercial - Medicaid - Medicaid -
Vaginal Cesarean Vaginal Cesarean

Charges Allowed Amount

Sources in Notes View.