Certified Nurse Midwives: The Right Option, Right Now.



NU 510 – Professional Role developmentCertified Nurse Midwives: The Right Option, Right Now.NU 510- Nursing Position/Role PaperTracy Hill6/28/2009In 2008, LMH and the only hospital-owned obstetric physician practice in Lawrence lost 408 Douglas County patients to the competition, up from 367 patients in 2007; that’s 30 percent outmigration! Over half (212) went to Overland Park Regional Medical Center (OPRMC) in Overland Park, KS. OPRMC has a Level 3 Neonatal Intensive Care Unit (NICU) and a relationship with LMHs main competitor, a Kansas City based group of obstetric providers, which includes CNMs (Dobies Healthcare Group, 2008). Birthing options are what pregnant women of the 21st century want! A midwife can be an excellent choice for maternity care for women who are healthy and expect to have a normal pregnancy. The addition of CNMs to LMH can help solve the outmigration issue, and offer comprehensive collaboration between staff which reflects the holistic nature of health promotion with the needs of the clients being emphasized above the needs of the different professional groups.What is different about the way that midwives provide care from the way that physicians provide care? The critical difference is midwives' art of doing "nothing" well; that is, being there with the woman, being vigilant to assure that things go well, but do not intervene or use technology unless it is necessary. In 2008, Lawrence Memorial Hospital (LMH) and the only hospital-owned obstetric physician practice in Lawrence lost 408 Douglas County patients to the competition, up from 367 patients in 2007; that’s 30 percent outmigration! Over half (212) went to Overland Park Regional Medical Center (OPRMC) in Overland Park, KS. OPRMC has a Level 3 Neonatal Intensive Care Unit (NICU) and a relationship with LMHs main competitor, a Kansas City based group of obstetric providers, which includes certified nurse midwives (CNM) (Dobies Healthcare Group, 2008). Birthing options are what pregnant women of the 21st century want! A midwife can be an excellent choice for maternity care for women who are healthy and expect to have a normal pregnancy. Expectant moms in Lawrence now have a diverse menu of delivery options to choose from, including midwifery. However, they cannot stay in Douglas County if they want the services of a certified nurse midwife when they deliver their child. Establishing at least one (preferably 2-3) full-time certified nurse midwife position(s), in Douglas County, KS, that offers birthing services at LMH will help meet the needs of the local community which currently does not have any CNMs that offer services at LMH. The CNM will work in collaboration with an existing group of family practice or obstetric physicians who are supportive and respectful of and encourage the midwifery model of care. There is currently only one hospital-owned obstetric physician practice in Lawrence, and they do not have CNMs on staff. The LMH owned obstetric group has one main competitor, a Kansas City based group of obstetric physicians with CNMs on staff, who have a Lawrence office. However, birthing services with this group are offered at two Kansas City area hospitals, not LMH, and require patients to drive to Kansas City for those services. A recent interview with Janice Early-Weas, Community Relations Director at LMH, revealed that current LMH bylaws allow for CNMs to practice at LMH, as long as there is a physician on LMHs medical staff with caesarean section privileges/credentialing who is willing to collaborate with the CNM. Currently, there are no physicians at LMH (130+ on staff) with C-Section privileges (approximately 8 physicians, including 5 of which are obstetric physicians) that are willing to collaborate with a CNM (J. Early-Weas, personal communication, June 23, 2009). Additionally, the Kansas City based group of obstetric providers is not currently interested in offering their services at LMH, citing one reason is they are interested in eventually moving all of their birthing services to Overland Park Regional Medical Center (OPRMC), in Overland Park, KS. LMH should consider offering and promoting more birthing options, including the addition of a midwife to the LMH owned obstetric physician group. A December 2008 focus group comprised of women of childbearing age who have or have not given birth in the Lawrence area said that the midwifery option was important CITATION Dob08 \l 1033 (Dobies Healthcare Group, 2008). Each year, hundreds of mothers leave Douglas County to have their babies. Of the 408 Douglas County patients (30 percent) previously stated that were lost to outmigration, over half (212) went to Overland Park Regional Medical Center (OPRMC) in Overland Park, KS. OPRMC has a Level 3 Neonatal Intensive Care Unit (NICU) and a relationship with LMHs main competitor, the Kansas City based group of obstetric providers, which includes CNMs CITATION Dob08 \l 1033 (Dobies Healthcare Group, 2008). Shawnee Mission Medical Center (SMMC) delivers the second highest number of Douglas County births CITATION Dob08 \l 1033 (Dobies Healthcare Group, 2008). Knowing the competitions strengths and weaknesses is imperative to any marketing plan. LMH believes it has the capacity and the assets to aggressively reverse the growing patient outmigration trend CITATION Dob08 \l 1033 (Dobies Healthcare Group, 2008). Due to the fact that women in Douglas County have a whole menu of delivery options to choose from, including midwifery, and that LMH by-laws allow midwife deliveries at the hospital, Lawrence obstetric physicians should consider the possible addition of a midwife to its practice CITATION Dob08 \l 1033 (Dobies Healthcare Group, 2008).To understand the need for a certified nurse midwife at LMH, one must first understand the role of a CNM. A certified nurse midwife is an advanced practice nurse with additional training around delivering babies and providing prenatal and postpartum care to women. Nurse-midwives are very involved in labor and delivery, sometimes never leaving the mother during the entire labor process. Today midwives are highly educated professionals who are often affiliated with a physician, have hospital privileges, and in most states, including Kansas, write prescriptions CITATION Dob08 \l 1033 (Dobies Healthcare Group, 2008). The CNM will be trained to recognize signs and symptoms that deviate from normal conditions and will consult with a physician who may become involved in the delivery if needed. The CNM will also provide both prenatal and postpartum care for both mothers and newborns. In addition, the CNM will provide family planning and birth control counseling, and normal gynecological services such as: physical and breast exams, pap smears, and preventive health screening CITATION All09 \l 1033 (Nurse Midwifery and Certified Nurse Midwifes, 2002-2009).In this newly developed position in Douglas County, KS, the CNM will offer a variety of services in women’s health care. While specializing in pregnancy and childbirth, the CNM will offer all aspects of women’s health care, focusing on education, wellness and personal attention. Health promotion is of particular importance to midwives who promote health rather than manage disease and ill health CITATION Ann05 \l 1033 (Beldon, 2005). The CNM will seek to respond positively to service changes to achieve the goal of multidisciplinary, non- hierarchical patient-centered services. The CNM will also be a facilitator of change and seek to use their influence to the benefit of the pregnant woman. Although the midwife has always had a role in public health, there will be an explicit need for the profession to direct its attention to a greater number of issues, such as teenage pregnancy, smoking cessation, drug awareness, and domestic violence. Much of the role of the midwife during pregnancy is in health promotion and a more explicit application of such may carry benefits in meeting government policy on public health CITATION Ann05 \l 1033 (Beldon, 2005). The CNM will frequently utilize holistic concepts of health to underpin their practice, hence health is described as being multi-dimensional, being physical, mental, emotional, societal, sexual and spiritual in nature CITATION Ann05 \l 1033 (Beldon, 2005).Increasing access to the Midwives Model of Care (MMOC) in all settings is essential to the health and wellbeing of childbearing women and their babies. The Midwives Model of Care is based on the fact that pregnancy and birth are normal life processes. The “midwives model of care” was developed in 1996, when midwifery groups worked together to write the definition that all the groups could use consistently in communicating with health care decision makers, after they realized that they needed a definition that would address the primary concerns of health care decision-makers about midwifery, and it would be a definition they would be likely to read CITATION The05 \l 1033 (The Midwives Model of Care, 2005). “Our hope and expectation was that once these decision-makers read/hear what THEY NEED to read/hear, they might begin to accept that midwifery itself is not "dangerous" and that the Midwives Model of Care and the midwives who provide it should be included in general health care CITATION The05 \l 1033 (The Midwives Model of Care, 2005). The goal is to remove obstacles to the MMOCs availability, and figure out how to make it available to as many women as possible, regardless of who is providing the care. CNMs also want the MMOC to become the standard of ideal that all maternity care providers can attempt to meet.The National Birth Policy Coalition supports legislative initiatives that promote the autonomous practice of Certified Professional Midwives and Certified Nurse-Midwives, and ensure the availability of safe, evidence-based care during pregnancy, labor, birth and postpartum CITATION The05 \l 1033 (The Midwives Model of Care, 2005). However, while it would be wonderful to incorporate the MMOC in this CNM position, one must also be aware that while midwives practice in many settings, it is still rare to get the Midwives Model of Care in a hospital setting. Typically, the most likely place to receive the Midwives Model of Care is in your home or a free-standing birth center, because usually it is difficult for caregivers to give the woman-centered, individualized Midwives Model of Care under the rules and standard practices of today's hospitals CITATION The05 \l 1033 (The Midwives Model of Care, 2005).The demographics of the potential customer base are residents from Douglas County, KS. Douglas County has the second fastest growing and fifth largest population in the state, with an estimated population of 112,123 in the year 2006, an increase of 11,984, or +12.0 percent over the previous six years CITATION Wik09 \l 1033 (Wikipedia, 2009). Based on population projections, the primary demographic LMH will need to target are women 18-44 (of childbearing age), specifically women 25-29 who have the highest birth rates nationally CITATION Dob08 \l 1033 (Dobies Healthcare Group, 2008). To increase market share, the current and only hospital owned obstetric physician practice in Lawrence will need to be attuned to the different values and communication preferences of its potential patients. LMH is the largest hospital in Douglas County. LMH is a 173-bed hospital in Lawrence, KS, and in collaboration with its medical staff, is dedicated to providing personal and high-quality health and wellness services for the people of Lawrence and the extended community. LMH is a community-owned, not-for-profit hospital that serves the health care needs of the community regardless of an individual's ability to pay. LMH receives no tax support from the city of Lawrence or Douglas County. Dedicated to improving the health of the community, LMH invests all excess revenues in services, equipment and facilities which further that mission CITATION Law09 \l 1033 (Lawrence Memorial Hospital, 2009). LMH has the opportunity to gain market share from smaller, growing communities in Douglas County with weak OB-GYN coverage CITATION Dob09 \l 1033 (Dobies Healthcare Group, 2009). By offering clinic hours in these smaller cities, LMH can significantly increase volume, once manpower issues are solved. The addition of CNMs to LMH can help solve the outmigration issue, and offer comprehensive collaboration between staff which reflects the holistic nature of health promotion with the needs of the clients being emphasized above the needs of the different professional groups.Another key issue with lack of access to midwifery care in Douglas County is the national cesarean rate. The US cesarean rate is now a staggering 26 percent. Midwives have a documented 10 percent cesarean rate in comparison. Cesareans comprise 29 percent of live births at LMH CITATION Placeholder1 \l 1033 (Dobies Healthcare Group, 2008), compared to 3.6 percent at the Birth and Women’s Center in Topeka, KS, a freestanding birthing center which employs midwives as obstetric providers CITATION Top09 \l 1033 (Topeka Birth and Women's Center, 2006). Unnecessary cesarean sections increase health care costs and contribute toward increased maternal and infant morbidity and mortality CITATION Cit03 \l 1033 (Citizens for Midwifery, 2003). In 2006, the most recent year for which statistics are available from the National Center for Health Statistics, certified nurse-midwives (CNMs) and certified midwives (CMs) attended 317,168 births, a record number. This represents 7.4% of all US births or 10.8% of all vaginal births, a 33% increase since 1996 CITATION Ame092 \l 1033 (American College of Nurse Midwives, 2009). In most European countries, where midwifery practices still dominate maternity care, the involvement of midwives is associated with good perinatal health outcomes CITATION Lyd04 \l 1033 (Lydon-Rochelle, 2004). In comparison to the United States, midwives in Ireland, Scotland, and England deliver more than 65 percent of all babies, and the proportions in Denmark, Sweden, Norway, Finland and Germany exceed 85 percent CITATION Lyd04 \l 1033 (Lydon-Rochelle, 2004). These countries have fewer obstetrical interventions than the U.S., as well as lower maternal, neonatal, and infant mortality rates and higher rates of breast-feeding. We must realize that pregnant women are a prize for healthcare providers, and compensation for them has intensified with the rise of HMO’s and other managed-care plans. Research suggests that most Americans with private health insurance are enrolled in managed care. At LMH, 31.4 percent of maternity payers are by a managed care plan, and 33.7 percent are by Blue Cross CITATION Dob08 \l 1033 (Dobies Healthcare Group, 2008). Due to the increased demand for options and including woman-to- woman care, the use of certified nurse midwives nationally has more than doubled since the 1980’s CITATION Dob08 \l 1033 (Dobies Healthcare Group, 2008). The popularity of midwives is also likely to increase as managed care responds to the less-expensive cost of midwifery CITATION Dob08 \l 1033 (Dobies Healthcare Group, 2008). In a news release from the American College of Nurse Midwives on June 12, 2009, The American College of Obstetricians and Gynecologists (ACOG) reaffirmed its support for equitable reimbursement for certified nurse-midwives CITATION Ame09 \l 1033 (American College of Nurse Midwives, 2009). The American Public Health Association also supports “increased access to midwifery services,” CITATION Cit03 \l 1033 (Citizens for Midwifery, 2003). While most state Medicaid plans reimburse midwives at the same rate as physician counterparts, a 35 percent disparity in reimbursement exists within the Medicare program. This payment inequity is a significant barrier to women’s access to midwifery care within the program CITATION Ame09 \l 1033 (American College of Nurse Midwives, 2009). Recently, however, significant developments on health care reform legislation occurred. On June 19, 2009, three committees within the House of Representatives issued an 852 page draft which included a provision to provide 100 percent reimbursement for CNMs under the Medicare program CITATION Ame091 \l 1033 (American College of Nurse Midwives, 2009)! The recommendation for adding CNMs to LMHs staff is grounded in research, trends and statistics nationally, regionally and locally. Today over 9,000 certified nurse-midwives practice throughout the United States; and over 38 nurse midwifery education programs are affiliated with a university or an accredited distance education program CITATION Cit03 \l 1033 (Citizens for Midwifery, 2003). Incomes for CNMs vary greatly depending on years and type of experience, the area of the country you work in, benefit packages, and employment of each CNM, such as whether a nurse-midwife works within an institution or practices on his or her own. LMH can and will benefit from adding CNMs to their staff. The community wants the option. The statistics continue to show an increase in outmigration of birthing services and one factor that contributes to the outmigration is that LMH does not offer midwifery services. Midwives are the right option, right now!References BIBLIOGRAPHY \l 1033 American College of Nurse Midwives. (2009, June 19). ACNM Health Reform Update. Retrieved June 19, 2009, from American College of Nurse Midwives: College of Nurse Midwives. (2009). ACOG Endorses Full Equity for CNM and CM Reimbursement under Medicare. Silver Spring, MD: American College of Nurse Midwives.American College of Nurse Midwives. (2009, February). CNM/CM-Attended Birth Statistics. Retrieved June 28, 2009, from American College of Nurse Midwives: , A. a. (2005, September). Health Promotion in pregnancy: the role of the midwife. The Journal of the Royal Society for the Promotion of Health , pp. 216-221.Citizens for Midwifery. (2003). Midwives: Essential for Affordable and Effective Maternity Care. Retrieved June 21, 2009, from Citizens for Midwifery: Healthcare Group. (2008). 2008-2010 LMH Obstetrics/Family Birthing Center Marketing Plan. Kansas City: Dobies Healthcare Group.Dobies Healthcare Group. (2008). LMH Market Study - Obstetrics. Kansas Ciry: Dobies Healthcare Group.Dobies Healthcare Group. (2009). Marketing Recommendations for Lawrence OB-GYN Specialists. Kansas City: Dobies Healthcare Group.Lawrence Memorial Hospital. (2009). Lawrence Memorial Hospital. Retrieved June 23, 2009, from Lawrence Memorial Hospital: , M. T. (2004). Minimal Intervention - Nurse-Midwives in the United States. The New England Journal of Medicine , 1929-1932.Nurse Midwifery and Certified Nurse Midwifes. (2002-2009). Retrieved June 19, 2009, from All Nursing Schools: Your guide to nursing education and careers: Midwives Model of Care. (2005). Retrieved June 21, 2009, from Citizens for Midwifery: mmoc/aboutdefine.aspxTopeka Birth and Women's Center. (2006). Retrieved June 23, 2009, from Topeka Birth and Women's Center: Wikipedia, t. f. (2009, June 23). Wikipedia. Retrieved June 27, 2009, from Douglas County, Kansas: ................
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