1. 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

2. 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

3. 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.

4. Patient Needs

5. Projected Numbers of Women, 2015-2060 Nearly 44 million more women (12 million of childbearing age) will need care in 2060. Sources in Notes View.

6. Projected Births in the United States – 2014-2060 The Census Bureau estimates a 14% increase in the number of births per year by the end of this timeframe. Sources in Notes View.

7. Pregnancy and Newborn Care Hospital Discharges Together Far Outnumber Discharges for any Other Major Diagnostic Category Sources in Notes View.

8. Workforce Demographics

9. 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. Sources in Notes View.

10. Maternity Care Providers per 10,000 Women Age 15+ Years The ratio has not changed appreciably in 16 years. Sources in Notes View.

11. First-Year OB/GYN Residents and Newly Certified CNMs/CMs, 1979 - 2014 The number of medical graduates entering OB/GYN residencies has remained relatively flat for three decades. New CNMs/CMs have been increasing recently. Sources in Notes View.

12. Distribution of OB/GYNs by Age More than 15,000 OB/GYNs will likely retire in the next decade, outpacing the rate of new OB/GYNs entering the profession by 20%. In 2013, 82.6% of first year OB/GYN residents and interns were women. Over time, the OB/GYN profession will become predominantly female. Sources in Notes View.

13. Multiple Studies Show Female Physicians Work Fewer Hours than Male Physicians 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 Average Hours Worked per Week, 2005-2007 Sources in Notes View.

14. Average Age at which ACOG Fellows Stop Practicing Obstetrics Sources in Notes View.

15. An Increasing Percent of OB/GYNs are Subspecializing Obstetrics/ Gynecology Maternal- Fetal Medicine Reproductive Endocrinology and Infertility Gynecologic Oncology Female Pelvic Medicine and Reconstructive Surgery In 2000 7% of OB/GYN residents entered a subspecialty fellowship. In 2012, 19.5% subspecialized. Many OB/GYN subspecialists do not typically attend births. Sources in Notes View.

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

17. Workforce Maldistribution Compounding the Problem

18. Obstetrician/Gynecologists per 100,000 Population Data Current as of 2011 Out of 3,142 U.S. Counties, 1,459 (46%) have no OB/GYN. 0 0.1 – 29.9 30.0 + OB/GYNs per 100,000 ACOG estimates that in 2011, there were 9.5 million people living in a county without a single OB/GYN. Sources in Notes View.

19. Certified Nurse-Midwives per 100,000 Population Data Current as of 2011 Out of 3,142 U.S. Counties, 1,758 (56%) have no CNM. 0 0.1 – 4.9 5.0 + CNMs per 100,000 Sources in Notes View.

20. CNMs and OB/GYNs per 100,000 Population Data Current as of 2011 Out of 3,142 U.S. Counties, 1,263 (40%) have no CNM or OB. 0 0.1 – 29.9 30.0 + CNMs & OB/GYNs per 100,000 Sources in Notes View.

21. Patient Population vs. Workforce Structure

22. Pregnancy and Risk Stratification Higher Risk Pregnancies Low-Moderate Risk Pregnancies There is no uniformly utilized definition of a high risk pregnancy. CDC estimates that in 2013, 83% of first time mothers were at low risk for a cesarean birth. 1 The NIH lists several high risk factors affecting 2- 10% of pregnancies. 2 More than half of pregnant women in the US are overweight or obese, which increases their risk. 3 It is reasonable to assume that the majority of women are low-moderate risk. Sources in Notes View.

23. Ideal Maternity Care Workforce Structure Higher Risk Pregnancies Low-Moderate Risk Pregnancies Providers Trained to Treat Higher Risk Providers Trained to Care for Women with Low- Moderate Risk Ideally, the workforce structure reflects the makeup of the patient population

24. Current Maternity Care Providers in the US OB/GYNs Medical degree & specialized residency Skilled in specialized surgical techniques and primary care Trained to attend low, moderate and high risk births and address complications and co- morbidities 99.9% of births they attend occur in hospitals. CNMs/CMs Masters Degree Skilled in fostering innate, hormonally driven processes of normal physiologic birth for women with low- moderate risk Provide primary care to women throughout the lifecycle 94.6% of the births they attend occur in hospitals. CPMs Most complete a non- accredited apprenticeship model of education Skilled in fostering innate, hormonally driven processes of normal physiologic birth for women of low risk Do NOT provide primary care 16.9% of births they attend occur in hospitals Both physicians and midwives are essential to an appropriately structured maternity care workforce.

25. 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.” Sources in Notes View. 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 in the US meet such standards.

26. Inter-Professional Collaboration – The Ideal Lower Risk Patients Moderate Risk Patients Higher Risk Patients Midwife-Led Care Physician-Led Care Jointly-Led 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.

27. Current US Maternal Care Workforce Structure Providers Trained to Treat Higher Risk (43,732 OB/GYN Fellows/Jr. Fellows*) Providers trained to care for women with normal Pregnancies (11,113 CNMs/ CMs and 1,800 CPMs*) The US maternity care workforce is upside down relative to patient needs. Higher Risk Pregnancies (1,500,000 births*) Normal Pregnancies (2.4 million births**) Sources in Notes View

28. How We Got Upside Down: Public Investment in Developing the Maternity Care Workforce Medicare policies say nothing with regard to whether CNMs/CMs can be paid for supervising medical interns, residents or student midwives. Teaching physicians are reimbursed for services of medical interns/residents under their supervision. While there may be midwives in teaching hospitals who are willing to precept CNM/CM students, these hospitals have a powerful economic incentive to favor education of OB/GYN residents. Sources in Notes View.

29. How We Got Upside Down: Public Investment in Developing the Maternity Care Workforce Medicare GME funds approximately 73% of medical residents. Others may be funded through Medicaid, the VA or commercial GME. Total GME spending amounts to approximately $127,000 per year for every resident in the U.S. Spending on each OB/GYN resident is reportedly $100,000/year The GNE demonstration funded approximately 0.17% of CNM/CM students (available in only one educational program) Total GNE spending on CNM/CM preceptor sites is approximately $25 per year for every CNM/CM student in the U.S. Sources and methods in Notes View.

30. How We Got Upside Down: The National Health Service Corps NHSC Funding goes to individuals in the form of scholarships or loan repayment, it does not reward clinical preceptors. Sources in Notes View.

31. Maternal Care Workforce Structure in Several Developed Countries: Midwives per Obstetrician Other developed countries have structured their maternity care workforce to match the needs of their population. The midwife-to-obstetrician ratio in the US is one-eighth the median among this group. Sources listed in Notes View.

32. Maximizing Midwifery: What is Possible Maternal mortality per 100,000 live births (2013) Sources in Notes View. Infant mortality - probability of dying by age 1 per 1,000 live births (2012) 4 4 4 5 9 28 2 2 2 3 3 6

33. Reasonable Expansion of Midwifery in the US Context Among the five states with the highest percentage of CNM/CM/CPM attended births in 2013 the average was 24%. Nationwide, in 2013, CNMs/CMs/CPMs attended 8.9% of all births. If CNMs/CM/CPMs had attended 24% of all 2013 births, they would have attended 594,300 additional births. Expansion of midwifery across the country to reflect what is already occurring in these five states would greatly alleviate current pressures on the OB/GYN workforce. Such expansion in the US is a reasonable goal. Sources in Notes View.

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

35. Physician Time as an Economic Asset When OB/GYNs focus on higher risk mothers, they more fully utilize their skillset, maximizing the return on personal and public investment in their education. MGMA studies show physician groups that use nurse practitioners are more economically healthy and physicians experience higher compensation because they focus on providing services that only they can render. Sources in Notes View.

36. Cost and Length of Education: CNMs/CMs as an Answer to the Maternity Care Provider Shortage Sources in Notes View. Educating midwives is comparatively rapid and economical. 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 RN prior to acceptance into the program. Average of Public and Private Institution Costs Note that physicians will likely incur additional expenses during their residency.

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

38. Precepting Students: The Most Significant Challenge to Creating More CNMs/CMs The GNE demonstration is reimbursing CNM preceptors with $15,000/year per student. CNM/CM students need precepting during approximately 80% of their two year program. Based on GNE expenditures, $24,000 is an appropriate amount needed to precept a student throughout their entire education. Sources in Notes View.

39. 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 precepting costs per practitioner to complete their residency or education Number of practitioners that could be supported with $10 million Average number of births attended annually by a single practitioner Additional births that could be attended annually by the additional skilled practitioners educated as a result of the $10 million investment Physicians$400,00025122*3,050 CNMs/CMs$24,00041770**29,190 Sources and methods in Notes View.

40. Supporting Midwifery Education: The ROI Sources and methodology in Notes View. Savings from Reduced Rates of Cesarean Birth Rate of cesarean birth among low- risk women.* 2015 costs for using this provider type to attend 70 low-risk women.** Medicaid portion of these costs Commercial portion of these costs Physicians14.66%$1,113,884$309,636$804,248 CNMs/CMs8.49%$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).

41. What Can be Done to Increase the Supply of CNMs/CMs?

42. 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

43. 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.

44. Potential Solutions: Helping Midwifery Students HRSA’s proposed FY 2016 budget would increase the NHSC field strength by 6,664. NHSC helps students afford their education, but does not address the challenges with obtaining more preceptor sites. Sources in Notes View.

45. 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 education for more advanced practice nurses. Sources in Notes View.

46. Potential Solutions: Georgia Preceptor Tax Incentive Program 480 hours of precepting to qualify. Certain medical, NP and PA students. Each 160 Hours. $1,000 Tax Deduction. Maximum deduction = $10,000 Sources in Notes View.

47. Potential Solutions: Reimbursing Midwife Educators Medicare pays teaching physicians for the services of the interns/residents that they are educating. CNMs/CMs frequently provide 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.

48. 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.

49. Appendix

50. Data from Risk Adjusted Comparative Studies in the US: % of Cesarean Births Sources and methods listed in “Notes” view. * Study 4 included overall cesarean rates, as well as C/S for primiparas and multiparas cesarean. * Study 7 included overall cesarean rate and primary cesarean rate. * Study 9 included overall cesarean rate and primary cesarean rate. 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 attended by Midwives (8.12%). Among all studies the averages of the respective rates are 14.66% and 8.49% Among the 234 midwifery practices reporting on 97,158 births in ACNM’s 2013 benchmarking data, the median rate of cesarean birth was 11.8%

51. Average Total Charges and Payments for Maternal and Newborn Care in the U.S. - 2010 Inflating these figures by the Medicare Economic Index (MEI) yields an estimate that in 2015 dollars commercial insurers are incurring costs of $18,961 for vaginal births and $28,826 for cesarean births, while Medicaid programs are paying $9,446 and $14,058 respectively. Sources in Notes View.