Lay midwives and the ObGyn: Is collaboration risky?

The picture gets a little trickier—and riskier—when we look at less-trained maternity providers.

A majority of CPMs lack adequate training

Few of the nation’s 1,400 CPMs in practice today meet the educational and training standards accepted by ACOG and the ACNM. The educational background of CPMs—known in some states as direct entry or lay midwives—varies widely across the nation. Unlike CNMs, CPMs are not required to have a nursing background. They practice primarily in out-of-hospital settings, including birthing centers and private homes. Many CPMs have no formal academic education or medical training, and their training requirements fall short of internationally established standards for midwives and traditional birth attendants.

Other relevant points:

• A person without a high school degree could be licensed as a CPM if he or she passed the certifying exam, observed 20 deliveries, and participated as the primary attendant in 10
• As a group, CPMs have not adopted home-birth patient-selection criteria that are based on generally accepted medical evidence or public safety
• The curriculum, clinical skills training, and experience of CPMs have not been approved by the American Midwifery Certification Board. Nor are they reviewed by the American Board of Obstetrics and Gynecology or the American Board of Family Medicine—recognized authorities in the certification of knowledge and skills associated with the practice of obstetrics.
• The North American Registry of Midwives’ Portfolio Evaluation Process requires midwives to be the primary care provider during 50 home births and to have 3 years’ experience. The average ObGyn resident gets this much experience in 1 month.

CPMs who lack a high school diploma and are apprentice-trained only (without core curriculum training and formal academic experience) clearly do not meet ACOG standards. Therefore, ACOG cautions its Fellows and the public that, for quality and safety reasons, it “does not support the provision of care by … midwives who are not certified by the American Midwifery Certification Board” [ACNM’s accreditation body]. Certification by this board, then, is a good indication of skill.

Requirements for successful collaborative practice

Where can you look for examples of collaboration that work, and for data on the effects of collaboration on health-care outcomes? Four articles in the September 2011 issue of Obstetrics and Gynecology highlight successful models of collaboration between ObGyns and CNMs in very different, well-established maternity programs.^6-9 In each article, the authors describe their collaborative practice model in some detail, offering guidance to others interested in successful collaboration. Common threads run through these narratives:

• trust
• communication
• mutual respect
• administrative support for continuing medical education
• consensus meetings
• common adherence to accepted guidelines
• an established support network for back-up and transfer.

The benefits to ObGyns include greater job satisfaction. Benefits to patients include improved health outcomes, as demonstrated, for example, in a model from Washington State: a high rate of vaginal delivery, low rate of cesarean birth, high rate of successful vaginal birth after cesarean (VBAC), and low rate of repeat cesarean delivery.⁷

ACOG’s policy on collaborative practice finds its origins just over 100 years ago in the Flexner report, quoted at the beginning of this article, which emphasized the need to ensure that medical care in the United States is of no less quality than in other parts of the world.¹

Medical education and quality of care have improved dramatically over the past century. ACOG is working to ensure the highest standards of care for pregnant women, standards no lower than for the rest of the population.

Collaboration is a time-honored tradition in ObGyn. Doing it right is key to patient safety.

Acknowledgment

The author acknowledges and thanks ACOG Executive Vice President Hal C. Lawrence III, MD, for his helpful review and comments

We want to hear from you! Tell us what you think.