Advantages Shown for Collaborative Physician/Midwifery OB Program

Washington, DC—A model of obstetric collaboration between certified nurse midwives and physicians at the University of Texas Medical Branch (UTMB) at Galveston showed that obstetric responsibilities can be amicably shared and patient outcomes optimized, according to a study presented at the 2011 American College of Obstetricians and Gynecologists (ACOG) annual meeting.

“This ongoing study has emphatically demonstrated that the collaboration of certified nurse midwives and physicians in an intrapartum setting has maintained the percentage of safe deliveries for uncomplicated cases and has facilitated cost-savings measures,” said Tony Wen, MD, chief, Education Division, and residency director, UTMB, who presented the study. Susan Nilsen, CNM, and Ruth Soulsby-Monroy, CNM, were coinvestigators.

Collaborative practice is becoming increasingly important given the current emphasis on healthcare reform and cost-containment, but there is a gap in understanding how collaboration between obstetricians and certified nurse midwives brings about high-quality, cost-effective labor and delivery services, the researchers noted.

“The ultimate goal of collaborative obstetric practice is to provide comprehensive quality healthcare services while offering patients a choice of providers who embrace compatible healthcare philosophies. UTMB has been one model of success,” Dr Wen said.

Division of labor
The inpatient collaborative team at UTMB consists of 17 certified nurse midwives, 10 maternal-fetal medicine physicians, 13 obstetric residents, 7 maternal-fetal medicine fellows, and 3 generalists.

The certified nurse midwives provide intrapartum management of low-risk pregnancies between 35 and 42 weeks gestation under a collaboratively established protocol. Services include management of labor, induction of labor, delivery, and the immediate postpartum period. In general, low-risk pregnancies do not involve preeclampsia, diabetes, fetal anomalies, or known intrauterine growth restriction. Certified nurse midwives also conduct postpartum rounds for 90% of vaginal deliveries.

Patients with medical or obstetric complications are managed by the physician team. They are responsible for antepartum services, intrapartum care, triage, obstetric surgical procedures, and postpartum care.

Certified Nurse Midwives Handle 33% of Births
In 2009, UTMB’s collaborative obstetric practice involved 11,956 triage encounters and 6220 deliveries. The certified nurse midwives service attended 2014 births, accounting for 32.4% of all deliveries. Of those pregnancies, more than 33% were nulliparous patients between 35 and 42 weeks gestation, whereas less than 2% were at 35 to 37 weeks gestation. Approximately 25% of the patients attended by certified nurse midwives were induced, 74% of which were after the due date.

On average, the midwives transferred less than 16% of their patients to the physician service. Of these, 65% required a primary cesarean section.

“Of particular note is the difference in the population for which the physicians provided care,” Dr Wen said. Physicians provided high-risk care for 1086 deliveries, which translates to approximately 26% of their population, in sharp contrast to the certified nurse midwives population of low-risk patients.

The model “frees each specialty to work with the patient population appropriate to their knowledge and training,” he said. “At our university, maternal-fetal medicine physicians need not attend normal spontaneous vaginal de liveries. They are instead available to work with our highly complicated patients.”

The delegation of high-risk patients to the physician service is a primary contributing factor to the success of our collaborative effort.” In addition, the model encourages research and teaching in areas in which the certified nurse midwives are actively involved.

Some Preferences Are Different
The collaborative care is evidencebased and congruent with ACOG guidelines, but the providers do not always practice identically, he said.

For example, for low-risk patients receiving induction, the certified nurse midwives service prefers oxytocin and intracervical Foley bulb induction, and misoprostol (Cytotec) as the agent for cervical ripening.

In contrast, the physician service uses the same methods and agents when attending high-risk patients, but usually prefers dinoprostone (Cervidil) over misoprostol. Amniotomy, intrauterine pressure catheters, and fetal scalp electrodes are used by both certified nurse midwives and physicians, he noted.

Collaboration will Provide Cost-Savings
Although the investigators did not conduct a formal cost analysis, Dr Wen pointed out that the collaborative model will emerge as cost-saving.

On average, institutions pay the certified midwives less than half the salary of a physician, although before 2011, institutions were reimbursed by the Centers for Medicare & Medicaid Services (CMS) for midwifery services at 65% of the physicians’ rate for the same work, he noted.

This disparate reimbursement rate would not seem to incentivize an institution to use cost-saving certified nurse midwives, he suggested. However, in anticipation of a shortage of primary care providers, Congress has set forth measures to reimburse for midwifery care at 100% of the physicians’ rate. Additional congressional provisions to be implemented by 2015 include a 10% bonus payment to institutions that employ certified nurse midwives whose primary services account for 60% of CMS-allowed charges.

“This increased reimbursement rate will significantly draw attention to resultant cost-savings in the use of certified nurse midwives in collaborative practice,” Dr Wen predicted. “Collectively, these changes will make abundantly obvious the financial advantages of establishing or enhancing an institution’s collaborative OB services.”