Nurse-midwife laborists add value to hospital-based care models
by Rima Jolivet, CNM, MPH
Emalie Gibbons Baker, CNM, arrives at St Mary’s Hospital at 7 a.m. Half an hour later she is scrubbed in, first assisting a community OB/GYN who performs a repeat cesarean delivery. By 9 a.m., the baby is safely delivered and resting with his mom, and the physician is seeing patients in her private practice a few miles from the hospital.
Now Baker cares for a nervous first-time mother in labor, sitting close to her bed and softly encouraging her through each contraction, praising her efforts when each pain subsides. She steps out to monitor an outpatient who has arrived for a labor check, performs a sterile speculum exam, and confirms the well-being of the fetus. Then reviews the signs of labor with the expectant mother, gives her a pep talk and a hug, and discharges her.
This is a typical start to a busy day for Baker, a certified nurse-midwife (CNM) laborist at St. Mary’s Hospital in Leonardtown, Md. CNM laborists like Baker work cooperatively with their collaborating physicians and midwife colleagues in the ambulatory setting and in the hospital, leaving their colleagues with time to care for high-risk women in the hospital and to hold office hours in their private practices.
Like most CNM laborists, Baker provides care during labor and the post-partum period for pregnant women and new mothers in the hospital setting. She oversees labor induction, augmentation, and pain management, including epidurals, for patients on the ward, works with the nursing staff, provides hands-on care for patients, provides first assists in cesarean deliveries, and evaluates pregnant patients who present to the emergency department (ED). When a new need arises, Baker can often provide the necessary service, and the list continues to grow as she adds circumcisions and interpretation of fetal fibronectin results to her responsibilities.
Certified nurse-midwives are a valuable addition to the field of hospital-based healthcare. The approximately 7,000 practicing certified nurse-midwives in the United States delivered more than 310,000 babies in 2003, representing more than 10% of the vaginal deliveries in this country.
Many people are unaware that 98% of CNM-attended deliveries in the United States occur in a hospital. Certified nurse-midwives are qualified professionals who have graduated from an accredited university-based program and passed a national certification exam. Baker, like all CNMs, is a registered nurse. She earned her master’s degree in midwifery in 1994 at State University of New York Downstate University, one of 40 midwifery education programs in the United States.
Certified nurse-midwives practice in a variety of settings, including hospital and office-based practices, community health centers, and public health facilities. CNMs are licensed in all 50 states. They are reimbursed by Medicare, are Medicaid-mandated service providers, and are widely included in managed care provider listings. CNMs are experts in the management of normal birth. Studies have demonstrated that the outcomes of nurse-midwifery care are at least equivalent to those of patients managed by physicians for normal maternity care, and patients repeatedly indicate high levels of satisfaction with the care provided by nurse-midwives.
“Having [Baker] at the hospital has been a big selling point for patients. She helps by massaging the patients who are anxious or need things explained to them. I think this provides the patients with a sense of security, and they also appreciate that this is a unique and different service we provide here,” says Valinda Nwadike, MD, an OB/GYN at St. Mary’s County who previously worked with nurse-midwives in a large urban hospital in Washington, D.C. “All in all, having [Baker] on board as a CNM laborist means better patient interaction and increased quality and continuity of care. It is a very useful tool, one that improves both patient care and our quality of life as community physicians. It’s a win-win situation.”
The Southern Maryland community served by St. Mary’s Hospital is quickly growing. The hospital serves as the birth site for the nearby Patuxent Naval Air Station. The number of births at the 100-bed facility recently jumped from 600-800 births a year to more than 1,000. The four OB/GYNs serving this county of 90,000 are all in private practice. With growing businesses, these community providers found that juggling busy outpatient schedules with inpatient demands for labor support or hospital-based procedures was resulting in disruption in their clinics, lost revenue, and frustration for them and their patients alike.
Collectively, the community OB/GYNs got together and decided to hire a CNM laborist to help cover the bases. Lawrence Tilley, MD, chief of obstetrics and gynecology at the hospital, had watched the success of the hospitalist model at St. Mary’s and has a certified nurse-midwife on staff at his private office. He finds that offering nurse-midwifery services in his practice acts as a draw for patients. At the hospital, he would like to add more midwives to the staff, for 24/7 coverage.
Hundreds of miles away, in a busy urban healthcare delivery system with different needs and rhythms than those in rural Maryland, the CNM laborist model also fits the bill. At Mt. Sinai Hospital in Chicago Laborist Darryn Dunbar, CNM, attends the births of nurse-midwifery patients served by the Access Community Health Network, a large healthcare organization that manages 44 Federally Qualified Health Centers in the Chicago area. The hospital sees 4,000 births a year, of which close to 10% are attended by midwives. Dunbar is one of two CNM laborists at Mt. Sinai who care for Access midwifery patients, most of whom are on Medicaid. He works solely in the hospital, providing inpatient coverage after hours and on weekends to the clients of a seven-midwife team that, with the addition of his laborist services, is able to offer almost continuous midwifery coverage.
“The goals were to extend midwifery coverage, to increase patient satisfaction and safety by having continuity of on-site care for this group of patients, … to improve staffing ratios in labor and delivery, and [to] provide relief for the residents and house officers,” says Dunbar.
His many years of experience as a full-scope CNM in busy, urban settings with high volume and increased social and medical risk factors make him well suited to providing care in this setting. In addition, in Illinois (as of this year) Dunbar can bill directly for his services under Medicaid and receives 100% of the physician reimbursement rate. He can also serve as the billing provider when he supervises the deliveries of residents in the hospital training program.
Dunbar is a valuable member of the OB team. He receives patients who come in through the ED and helps with OB triage, first assists with cesarean deliveries on occasion, and “runs the board” when the residents are off the floor for educational obligations, are in surgery, or are busy with other patients. The nursing staff, house attendings, and residents have all come to rely on his watchful eyes and helping hands.
Nurse-midwives, according to their professional philosophy, believe the best model of healthcare for a woman and her family is one that promotes a continuous and compassionate partnership, including individualized methods of care guided by the best evidence available, therapeutic use of human presence, and skillful communication. They believe in watchful waiting and non-intervention in normal processes, the appropriate use of interventions and technology for current or potential health problems, and consultation, collaboration, and referral with other members of the healthcare team, as needed, to provide optimal healthcare.
The ability to provide this kind of care is one of the greatest strengths certified nurse-midwives bring to the communities they serve, especially in busy hospitals where the healthcare needs of women and their newborns are great and the demands on providers’ time are high.
Struggling to increase patient safety, decrease costs, and optimize productivity while maintaining good health outcomes, hospitals are increasingly turning to nurse-midwives. Meanwhile, many community OB/GYN providers are reducing their OB call due to burnout and quality of life issues, increased liability insurance premiums, and fear of litigation. Resident work-hours have decreased due to safety concerns and mandated work limits. There is a need for providers who can care for laboring women in the hospital setting, providing continuity and quality of service during their hospital admission. On-site CNM laborists fill in the gap.
Having a laborist on board in the OB/GYN department of the hospital helps Yaacov Zamel, MD, a pediatric hospitalist at St. Mary’s, by allowing him to establish a working relationship with someone whose availability and practice patterns he can rely on. He also notes that this improves care for the women and babies. “The better the support for OB, the better it is for newborns. Ultimately, more patients will want to come here,” says Dr. Zamel.
Dr. Nwadike agrees that having a nurse-midwife on staff increases patient safety and the quality of care. “In our community, we needed help specifically with coverage for hospital patients and procedures, and Baker’s skills are the perfect match,” says Dr. Nwadike. “Now she is an invaluable resource and can do all of those things, as well as provide ED triage, care for unassigned patients, or manage precipitous deliveries. As a continuous presence on labor and delivery, she is a great resource for patients and can provide them with more depth, more education. There are really limitless possibilities for her role to expand.”
As experts in caring for healthy women and their newborns, with a history of achieving excellent perinatal outcomes while caring for underserved populations, certified nurse-midwives are ideal healthcare providers for women who arrive at hospitals seeking quality care. “Working as a laborist, I enjoy being able to use all of my skills. That has been very exciting,” says Baker.
At 4:30 p.m., Baker wraps up for the day. The community OB/GYN on call arrives from his office to assume care for a laboring patient on his panel. Baker updates him on the woman’s status, than wraps the patient in a warm parting hug. TH
Rima Jolivet is the senior technical advisor at the American College of Nurse-Midwives.
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