The Role of Certified NurseMidwives and Certified Midwives

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The Role of Certified Nurse-Midwives and Certified Midwives in Ensuring Women’s Access to Skilled

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

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

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 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 approximately 1, 800 CPMs in the US and 83% of the births they attend occur in an out of hospital setting.

Patient Needs

Patient Needs

Projected Numbers of Women, 2015 -2060 190, 000 170, 000 150, 000 130, 000

Projected Numbers of Women, 2015 -2060 190, 000 170, 000 150, 000 130, 000 Nearly 44 million more women (12 million of childbearing age) will need care in 2060. 110, 000 Age 15+ Age 15 -49 90, 000 70, 000 Sources in Notes View. 2060 2058 2056 2054 2052 2050 2048 2046 2044 2042 2040 2038 2036 2034 2032 2030 2028 2026 2024 2022 2020 2018 2016 2014 50, 000

Projected Births in the United States – 2014 -2060 5, 000 4, 800, 000

Projected Births in the United States – 2014 -2060 5, 000 4, 800, 000 4, 600, 000 4, 400, 000 4, 200, 000 4, 000 3, 800, 000 The Census Bureau estimates a 14% increase in the number of births per year by the end of this timeframe. 3, 600, 000 3, 400, 000 3, 200, 000 Sources in Notes View. 2060 2058 2056 2054 2052 2050 2048 2046 2044 2042 2040 2038 2036 2034 2032 2030 2028 2026 2024 2022 2020 2018 2016 2014 3, 000

Pregnancy and Newborn Care Hospital Discharges Together Far Outnumber Discharges for any Other Major

Pregnancy and Newborn Care Hospital Discharges Together Far Outnumber Discharges for any Other Major Diagnostic Category Circulatory System 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, 500, 000 2, 500, 000 3, 000 Number of Discharges Sources in Notes View. 4, 796, 1 75 3, 500, 000 4, 500, 000 5, 000

Workforce Demographics

Workforce Demographics

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

Maternity Care Providers per 10, 000 Women Age 15 -49 Years Providers per 10, 000 Women 10. 00 9. 00 • • 8. 00 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. 7. 00 6. 00 5. 00 4. 00 3. 00 2. 00 1. 00 OB/GYNs Sources in Notes View. CNMs/CMs Total 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 0. 00

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

Maternity Care Providers per 10, 000 Women Age 15+ Years Providers per 10, 000 Women 10. 00 9. 00 8. 00 The ratio has not changed appreciably in 16 years. 7. 00 6. 00 5. 00 4. 00 3. 00 2. 00 1. 00 OB/GYNs Sources in Notes View. CNMs/CMs Total 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 0. 00

First-Year OB/GYN Residents and Newly Certified CNMs/CMs, 1979 - 2014 2, 000 1, 800

First-Year OB/GYN Residents and Newly Certified CNMs/CMs, 1979 - 2014 2, 000 1, 800 1, 600 • • The number of medical graduates entering OB/GYN residencies has remained relatively flat for three decades. 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 1 st Year OB/GYN Residents Sources in Notes View. 2007 2008 2009 2010 2011 Newly Certified CNMs/CMs 2012 2013 2014

Distribution of OB/GYNs by Age 55 -64 Yrs Age Males Sources in Notes View.

Distribution of OB/GYNs by Age 55 -64 Yrs Age Males Sources in Notes View. Females 20. 10% 31. 20% 25. 30% 45 -54 Yrs 11. 80% 35 -44 Yrs 26. 90% 29. 80% 16. 60% 24. 70% <35 Yrs 3. 40% • 5. 20% 50% 45% 40% 35% 30% 25% 20% 15% 10% 5% 0% 65+ Yrs • • 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.

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

Average Hours Worked per Week, 2005 -2007 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 Sources in Notes View.

Average Age at which ACOG Fellows Stop Practicing Obstetrics 55 43. 8 43. 1

Average Age at which ACOG Fellows Stop Practicing Obstetrics 55 43. 8 43. 1 40. 8 39. 2 39. 5 35 51. 9 51. 7 42 40 51 51. 2 48. 4 45 50. 2 Age (years) 50 Females 30 25 1992 1996 1999 2003 Year of Study Sources in Notes View. 2006 Males 2009

An Increasing Percent of OB/GYNs are Subspecializing Reproductive Endocrinology and Infertility Gynecologic Oncology In

An Increasing Percent of OB/GYNs are Subspecializing Reproductive Endocrinology and Infertility Gynecologic Oncology 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. Obstetrics/ Gynecology Maternal. Fetal 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

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

Workforce Maldistribution Compounding the Problem

Obstetrician/Gynecologists per 100, 000 Population Data Current as of 2011 ACOG estimates that in

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/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,

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 &

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

Patient Population vs. Workforce Structure

Pregnancy and Risk Stratification Higher Risk Pregnancies Low-Moderate Risk Pregnancies Sources in Notes View.

Pregnancy and Risk Stratification Higher Risk Pregnancies Low-Moderate Risk Pregnancies Sources in Notes View. 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 210% 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.

Ideal Maternity Care Workforce Structure Higher Risk Pregnancies Low-Moderate Risk Pregnancies Ideally, the workforce

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

Current Maternity Care Providers in the US OB/GYNs CNMs/CMs CPMs • Medical degree &

Current Maternity Care Providers in the US OB/GYNs CNMs/CMs CPMs • 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 comorbidities • 99. 9% of births they attend occur in hospitals. • Masters Degree • Skilled in fostering innate, hormonally driven processes of normal physiologic birth for women with lowmoderate risk • Provide primary care to women throughout the lifecycle • 94. 6% of the births they attend occur in hospitals. • Most complete a nonaccredited 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.

CNMs/CMs are Appropriate Providers for Low-Moderate Risk Pregnancy • The Lancet - 2014 “Provision

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.

Inter-Professional Collaboration – The Ideal Lower Risk Patients Midwife-Led Care Moderate Risk Patients Higher

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

Current US Maternal Care Workforce Structure Providers Trained to Treat Higher Risk (43, 732

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*) Sources in Notes View 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**)

$14, 000, 000 $12, 000, 000 $15, 000, 000 How We Got Upside Down:

$14, 000, 000 $12, 000, 000 $15, 000, 000 How We Got Upside Down: Public Investment in Developing the Maternity Care Workforce $4, 000, 000 $2, 000, 000 $0 $50, 000 $6, 000, 000 $224, 000 $8, 000, 000 $283, 000 $10, 000, 000 2014 Expenditures Graduate Medical Education National Health Service Corps Nursing Workforce Development (Title VIII of the PHSA) Graduate Nursing Education Demonstration Sources in Notes View. • 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.

How We Got Upside Down: Public Investment in Developing the Maternity Care Workforce 6,

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 be funded through Medicaid, the VA or commercial GME. 5, 000 4, 000 3, 670 4 2, 000 1, 000 2, 395 1, 358 0 OB/GYN Residents 2014 CNN/CM Students Not supported Through GME or GNE Supported through GNE or GME Sources and methods in Notes View. 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.

How We Got Upside Down: The National Health Service Corps 3, 000 51 40

How We Got Upside Down: The National Health Service Corps 3, 000 51 40 500 130 1, 000 157 1, 500 2, 873 2, 000 2, 405 Individual Recipients 2, 500 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. NHSC Funding goes to individuals in the form of scholarships or loan repayment, it does not reward clinical preceptors.

0. 32 0. 40 0. 83 0. 87 1. 00 1. 06 1. 57

0. 32 0. 40 0. 83 0. 87 1. 00 1. 06 1. 57 1. 94 2. 54 1. 21 2. 00 2. 57 4. 00 3. 23 6. 00 3. 83 8. 00 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. 3. 94 10. 00 4. 39 12. 00 • 4. 52 14. 00 6. 54 16. 00 • 9. 67 18. 00 19. 49 20. 00 15. 67 Maternal Care Workforce Structure in Several Developed Countries: Midwives per Obstetrician Sources listed in Notes View. US Au UK st ra l Be ia lg iu m Fin la nd Fr an De ce nm a Sw rk ed Ge en rm an y J Ne ap th an er la nd Au s st ria Ko r Po ea rtu ga l Ita l Gr y ee ce Lu Sp xe ain m bo Si urg ng ap or Ca e na da 0. 00

100% 4 4 4 5 9 28 90% 2 2 2 3 3 6

100% 4 4 4 5 9 28 90% 2 2 2 3 3 6 78% 77% 75% Maximizing Midwifery: What is Possible Finland Iceland Sweden 80% Maternal mortality per 100, 000 live births (2013) 50% 40% 72% 60% 72% 70% Denmark France 9% 30% 20% 10% 0% Percent of Births Attended by Midwives Sources in Notes View. US Infant mortality probability of dying by age 1 per 1, 000 live births (2012)

Reasonable Expansion of Midwifery in the US Context Among the five states with the

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/CPMs attended 8. 9% of all births. • 100% 90% 80% • 70% 60% 50% • • 40% 30% New Hampshire 19. 8% New Mexico Vermont 20. 8% Alaska 22. 3% 0% 26. 3% 10% 30. 7% 20% Oregon Percent of Births Attended by CNMs/CPMs Sources in Notes View. • 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.

Physician Time as an Economic Asset Educating OB/GYNs entails enormous public and personal investment

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

Physician Time as an Economic Asset When OB/GYNs focus on higher risk mothers, they

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. Sources in Notes View. 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.

Cost and Length of Education: CNMs/CMs as an Answer to the Maternity Care Provider

Cost and Length of Education: CNMs/CMs as an Answer to the Maternity Care Provider Shortage Total Cost of Education Years to Complete Education $250, 000 4 5 4 3 2 4 0 2 1 0 $200, 000 $150, 000 $100, 000 $50, 000 $0 OB/GYNs CNMs/CMs Medical School or Midwifery School Residency • 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. Sources in Notes View. Medical School Public Institution $53, 505 6 Educating midwives is comparatively rapid and economical. $208, 138 7 $131, 556 8 CNM/CM Education Private Institution Average of Public and Private Institution Costs Note that physicians will likely incur additional expenses during their residency.

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

Precepting Students: The Most Significant Challenge to Creating More CNMs/CMs • • 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. Sources in Notes View. • • 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.

Precepting Students: The Most Significant Challenge to Creating More CNMs/CMs Most CNM/CM Preceptors Are

Precepting Students: The Most Significant Challenge to Creating More CNMs/CMs Most CNM/CM Preceptors Are Unpaid 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% • • 38% 62% • Unpaid Midwifery Preceptors Paid Midwifery Preceptors Sources in Notes View. 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.

Funding for Maternity Care Workforce Development What would the public get for an investment

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, 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

Supporting Midwifery Education: The ROI Savings from Reduced Rates of Cesarean Birth Rate of cesarean birth among lowrisk women. * 2015 costs for using this provider type to attend 70 low-risk women. ** Physicians 14. 66% $1, 113, 884 $309, 636 $804, 248 CNMs/CMs 8. 49% $1, 081, 191 $300, 931 $780, 260 • • Medicaid portion of these costs Commercial portion of these costs 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?

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

Potential Solutions • • • Identify Shortage Areas Funding for the NHSC Graduate Nurse

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

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 $700, 000 $600, 000

Potential Solutions: Helping Midwifery Students National Health Service Corps Expenditures $700, 000 $600, 000 $500, 000 $400, 000 $300, 000 $200, 000 $100, 000 $ 810, 000 $800, 000 $ 287, 370, 000 $900, 000 $0 FY 2015 Appropriation FY 2016 Presidential Budget Sources in Notes View. • 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.

Potential Solutions: The Graduate Nurse Education Demonstration $200 Million given to 5 hospitals over

Potential Solutions: The Graduate Nurse Education Demonstration $200 Million given to 5 hospitals over 4 years Sources in Notes View. Hospitals partner with schools of nursing and community clinical sites… …to provide clinical education for more advanced practice nurses.

Potential Solutions: Georgia Preceptor Tax Incentive Program Certain medical, NP and PA students. 480

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

Potential Solutions: Reimbursing Midwife Educators Medicare pays teaching physicians for the services of the

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.

Changes to Medical Education • Have medical students get exposure to obstetrics through mechanisms

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

Appendix

Data from Risk Adjusted Comparative Studies in the US: % of Cesarean Births Physician

Data from Risk Adjusted Comparative Studies in the US: % of Cesarean Births Physician Attended Births 34. 00% Study 7 - 2002 Study 8 - 2003 Study 9 - 2006 2. 44% 7. 93% 12. 40% 16. 60% 13. 00% 10. 70% 15. 90% 13. 60% 8. 80% 19. 30% 13. 00% Study 5 - 1995 5. 60% Study 4 - 1994* 1. 93% 12. 73% 18. 07% 8. 51% 4. 00% Study 3 - 1993 6. 67% Study 1 - 1992 9. 75% 0% 12. 30% 2. 14% 5% 0. 40% 10% 2. 00% 12. 88% 15. 60% 25. 80% 20% 19. 10% 25% 13. 70% 8. 40% 30% 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% Study 11 2015 Midwife Attended 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 the 234 midwifery practices reporting on 97, 158 births in ACNM’s 2013 benchmarking data, the median rate of cesarean birth was 11. 8%

Average Total Charges and Payments for Maternal and Newborn Care in the U. S.

Average Total Charges and Payments for Maternal and Newborn Care in the U. S. - 2010 $60, 000 $50, 000 Commercial Vaginal Commercial Cesarean Charges Sources in Notes View. $29, 800 $27, 866 $0 $18, 329 $10, 000 $32, 093 $20, 000 Medicaid - Vaginal Allowed Amount Medicaid Cesarean $13, 590 $50, 373 $30, 000 $9, 131 $51, 125 $40, 000 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.