1. 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
2. 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
3. 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
are 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 are approximately 1,800 CPMs in the US and 83% of the births they attend occur in
an out of hospital setting.
5. Projected Numbers of Women, 2015-2060
50,000,000
70,000,000
90,000,000
110,000,000
130,000,000
150,000,000
170,000,000
190,000,000
2014
2016
2018
2020
2022
2024
2026
2028
2030
2032
2034
2036
2038
2040
2042
2044
2046
2048
2050
2052
2054
2056
2058
2060
Age 15+
Age 15-49
Nearly 44 million more women (12 million
of childbearing age) will need care in 2060.
Sources in Notes View.
6. Projected Births in the United States – 2014-2060
3,000,000
3,200,000
3,400,000
3,600,000
3,800,000
4,000,000
4,200,000
4,400,000
4,600,000
4,800,000
5,000,000
2014
2016
2018
2020
2022
2024
2026
2028
2030
2032
2034
2036
2038
2040
2042
2044
2046
2048
2050
2052
2054
2056
2058
2060
The Census Bureau estimates a 14% increase in the
number of births per year by the end of this timeframe.
Sources in Notes View.
7. Pregnancy and Newborn Care Hospital Discharges Together Far
Outnumber Discharges for any Other Major Diagnostic Category
0 500,000 1,000,000 1,500,000 2,000,000 2,500,000 3,000,000 3,500,000 4,000,000 4,500,000 5,000,000
Infectious & Parasitic Diseases
Mental
Kidney & Urinary Tract
Nervous System
Digestive System
Musculoskeletal System & Conn Tissue
Respiratory System
Newborns & Other Neonates
Pregnancy, Childbirth
Circulatory System
1,428,045
1,428,060
1,671,380
2,192,941
3,242,725
3,251,134
3,549,166
3,933,511
4,160,286
4,796,175
Number of Discharges
Sources in Notes View.
9. Maternity Care Providers per 10,000 Women Age 15-49 Years
0.00
1.00
2.00
3.00
4.00
5.00
6.00
7.00
8.00
9.00
10.00
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
Providers
per
10,000
Women
OB/GYNs CNMs/CMs Total
• 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.
Sources in Notes View.
10. Maternity Care Providers per 10,000 Women Age 15+ Years
0.00
1.00
2.00
3.00
4.00
5.00
6.00
7.00
8.00
9.00
10.00
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
Providers
per
10,000
Women
OB/GYNs CNMs/CMs Total
The ratio has not changed appreciably in 16 years.
Sources in Notes View.
11. First-Year OB/GYN Residents and Newly Certified CNMs/CMs, 1979 - 2014
0
200
400
600
800
1,000
1,200
1,400
1,600
1,800
2,000
1979 1987 1993 1998 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014
1st Year OB/GYN Residents Newly Certified CNMs/CMs
• The number of medical graduates entering OB/GYN
residencies has remained relatively flat for three decades.
• New CNMs/CMs have been increasing recently.
Sources in Notes View.
12. Distribution of OB/GYNs by Age
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
50%
<35 Yrs 35-44 Yrs 45-54 Yrs 55-64 Yrs 65+ Yrs
5.20%
16.60%
26.90%
31.20%
20.10%
24.70%
29.80%
25.30%
11.80%
3.40%
Age
Males Females
• 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.
Sources in Notes View.
13. 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
Average
Hours
Worked
per
Week,
2005-2007
Sources in Notes View.
14. Average Age at which ACOG Fellows
Stop Practicing Obstetrics
25
30
35
40
45
50
55
1992 1996 1999 2003 2006 2009
50.2
48.4
51.2
51
51.7
51.9
39.5
39.2
40.8
42
43.1
43.8
Age
(years)
Year of Study
Males
Females
Sources in Notes View.
15. An Increasing Percent of OB/GYNs are Subspecializing
Obstetrics/
Gynecology
Maternal-
Fetal
Medicine
Reproductive
Endocrinology
and Infertility
Gynecologic
Oncology
Female Pelvic
Medicine and
Reconstructive
Surgery
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.
Sources in Notes View.
16. Bottom Line: Serious Challenges
Static entries into
OB/GYN residencies
and increasing
subspecialization
Changes in provider
demographics
Increasing patient
needs
Serious
challenges with
ensuring skilled
attendants
at birth
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.
18. Obstetrician/Gynecologists per 100,000 Population
Data Current as of 2011
Out of 3,142 U.S. Counties, 1,459 (46%) have no OB/GYN.
0
0.1 – 29.9
30.0 +
OB/GYNs per 100,000
ACOG estimates
that in 2011,
there were 9.5
million people
living in a county
without a single
OB/GYN.
Sources in Notes View.
19. Certified Nurse-Midwives per 100,000 Population
Data Current as of 2011
Out of 3,142 U.S. Counties, 1,758 (56%) have no CNM.
0
0.1 – 4.9
5.0 +
CNMs per 100,000
Sources in Notes View.
20. CNMs and OB/GYNs per 100,000 Population
Data Current as of 2011
Out of 3,142 U.S. Counties, 1,263 (40%) have no CNM or OB.
0
0.1 – 29.9
30.0 +
CNMs & OB/GYNs
per 100,000
Sources in Notes View.
22. Pregnancy and Risk Stratification
Higher
Risk
Pregnancies
Low-Moderate
Risk
Pregnancies
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 2-
10% 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.
Sources in Notes View.
23. Ideal Maternity Care Workforce
Structure
Higher
Risk
Pregnancies
Low-Moderate
Risk
Pregnancies
Providers
Trained to
Treat Higher Risk
Providers
Trained to Care for
Women with Low-
Moderate Risk
Ideally, the workforce
structure reflects the
makeup of the
patient population
24. Current Maternity Care Providers in the US
OB/GYNs
• 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 co-
morbidities
• 99.9% of births they
attend occur in hospitals.
CNMs/CMs
• Masters Degree
• Skilled in fostering
innate, hormonally
driven processes of
normal physiologic birth
for women with low-
moderate risk
• Provide primary care to
women throughout the
lifecycle
• 94.6% of the births they
attend occur in hospitals.
CPMs
• Most complete a non-
accredited
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.
25. 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.
26. Inter-Professional Collaboration – The Ideal
Lower
Risk
Patients
Moderate
Risk
Patients
Higher
Risk
Patients
Midwife-Led
Care
Physician-Led
Care
Jointly-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.
27. 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*)
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**)
Sources in Notes View
28. How We Got Upside Down:
Public Investment in Developing the Maternity Care Workforce
$0
$2,000,000,000
$4,000,000,000
$6,000,000,000
$8,000,000,000
$10,000,000,000
$12,000,000,000
$14,000,000,000 $15,000,000,000
$283,000,000
$224,000,000
$50,000,000
2014 Expenditures
Graduate Medical Education
National Health Service Corps
Nursing Workforce Development (Title VIII of the PHSA)
Graduate Nursing Education Demonstration
• 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.
Sources in Notes View.
29. How We Got Upside Down:
Public Investment in Developing the Maternity Care Workforce
0
1,000
2,000
3,000
4,000
5,000
6,000
OB/GYN
Residents
CNN/CM
Students
1,358
2,395
3,670
4
2014
Supported through GNE or GME
Not supported Through GME or GNE
• Medicare GME funds approximately
73% of medical residents. Others may
be funded through Medicaid, the VA or
commercial GME.
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.
Sources and methods in Notes View.
30. How We Got Upside Down:
The National Health Service Corps
0
500
1,000
1,500
2,000
2,500
3,000 2,405
2,873
157
130
51
40
Individual
Recipients
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
NHSC Funding goes to
individuals in the form
of scholarships or loan
repayment, it does
not reward clinical
preceptors.
Sources in Notes View.
31. Maternal Care Workforce Structure in Several Developed Countries:
Midwives per Obstetrician
0.00
2.00
4.00
6.00
8.00
10.00
12.00
14.00
16.00
18.00
20.00
19.49
15.67
9.67
6.54
4.52
4.39
3.94
3.83
3.23
2.57
2.54
1.94
1.57
1.21
1.06
1.00
0.87
0.83
0.40
0.32
• 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.
Sources listed in Notes View.
32. Maximizing Midwifery: What is Possible
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Finland Iceland Sweden Denmark France US
78%
77%
75%
72%
72%
9%
Percent of Births Attended by Midwives
Maternal mortality
per 100,000 live
births (2013)
Sources in Notes View.
Infant mortality -
probability of
dying by age 1 per
1,000 live births
(2012)
4 4 4 5 9 28
2 2 2 3 3 6
33. Reasonable Expansion of Midwifery in the US Context
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Alaska New
Mexico
Vermont New
Hampshire
Oregon
30.7%
26.3%
22.3%
20.8%
19.8%
Percent of Births Attended by CNMs/CMs/CPMs
• Among the five states with the
highest percentage of
CNM/CM/CPM attended births in
2013 the average was 24%.
• Nationwide, in 2013,
CNMs/CMs/CPMs attended 8.9%
of all births.
• 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.
Sources in Notes View.
34. 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
35. 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.
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.
Sources in Notes View.
36. Cost and Length of Education:
CNMs/CMs as an Answer to the Maternity Care Provider Shortage
0
1
2
3
4
5
6
7
8
OB/GYNs CNMs/CMs
4
2
4
0
Years to Complete Education
Medical School or Midwifery School
Residency
$0
$50,000
$100,000
$150,000
$200,000
$250,000
Medical School CNM/CM
Education
$131,556
$53,505
$208,138
Total Cost of Education
Public Institution Private Institution
Sources in Notes View.
Educating
midwives is
comparatively
rapid and
economical.
• 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.
Average of Public and Private Institution Costs
Note that physicians will likely incur additional expenses
during their residency.
37. Precepting Students: The Most Significant Challenge to
Creating More CNMs/CMs
• 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.
Sources in Notes View.
• 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.
38. Precepting Students: The Most Significant Challenge to
Creating More CNMs/CMs
0%
20%
40%
60%
80%
100%
62%
38%
Most CNM/CM Preceptors
Are Unpaid
Unpaid Midwifery Preceptors
Paid Midwifery Preceptors
• 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.
Sources in Notes View.
39. 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.
40. Supporting Midwifery Education: The ROI
Sources and methodology in Notes View.
Savings from Reduced Rates of Cesarean Birth
Rate of cesarean
birth among low-
risk women.*
2015 costs for using this
provider type to attend
70 low-risk women.**
Medicaid portion
of these costs
Commercial
portion of these
costs
Physicians 14.66% $1,113,884 $309,636 $804,248
CNMs/CMs 8.49% $1,081,191 $300,931 $780,260
• 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).
41. What Can be Done to Increase the
Supply of CNMs/CMs?
42. 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
43. 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.
44. Potential Solutions: Helping Midwifery Students
$0
$100,000,000
$200,000,000
$300,000,000
$400,000,000
$500,000,000
$600,000,000
$700,000,000
$800,000,000
$900,000,000
$287,370,000
$810,000,000
National Health Service Corps
Expenditures
FY 2015 Appropriation
FY 2016 Presidential Budget
• 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.
Sources in Notes View.
45. Potential Solutions:
The Graduate Nurse Education Demonstration
$200 Million
given to 5
hospitals
over 4 years
Hospitals partner with
schools of nursing and
community clinical sites…
…to provide
clinical education
for more advanced
practice nurses.
Sources in Notes View.
46. Potential Solutions:
Georgia Preceptor Tax Incentive Program
480 hours of
precepting to
qualify.
Certain medical,
NP and PA
students.
Each 160
Hours.
$1,000 Tax
Deduction.
Maximum deduction = $10,000
Sources in Notes View.
47. 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.
48. 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.
50. Data from Risk Adjusted Comparative Studies in the US: % of Cesarean Births
0%
5%
10%
15%
20%
25%
30%
Study
1 -
1992
Study
2 -
1993
Study
3 -
1993
Study
4 -
1994
Study
4 -
1994*
Study
4 -
1994*
Study
5 -
1995
Study
6 -
1997
Study
7 -
2002
Study
7 -
2002*
Study
8 -
2003
Study
9 -
2006*
Study
9 -
2006
Study
10 -
2013
Study
11 -
2015
0.40%
12.30%
4.00%
12.88%
18.07%
6.67%
19.30%
13.60%
25.80%
13.70%
19.10%
15.60%
34.00%
16.60%
7.93%
2.14%
9.75%
2.00%
8.51%
12.73%
1.93%
13.00%
8.80%
15.90%
8.40%
10.70%
5.60%
13.00%
12.40%
2.44%
Physician Attended Births 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 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%
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%
51. Average Total Charges and Payments for
Maternal and Newborn Care in the U.S. - 2010
$0
$10,000
$20,000
$30,000
$40,000
$50,000
$60,000
Commercial -
Vaginal
Commercial -
Cesarean
Medicaid -
Vaginal
Medicaid -
Cesarean
$32,093
$51,125
$29,800
$50,373
$18,329
$27,866
$9,131
$13,590
Charges Allowed Amount
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.
Sources in Notes View.
Editor's Notes
US Census Bureau: https://www.census.gov/population/projections/data/national/2014/downloadablefiles.html
US Census Bureau: https://www.census.gov/population/projections/data/national/2014/downloadablefiles.html
Source: http://hcupnet.ahrq.gov/HCUPnet.jsp Last accessed 4/7/15.
“Maternal Care Providers” includes OB/GYNs (Fellows and Jr. Fellows), and CNMs/CMs.
Source: OB/GYN data are per private communication with ACOG and also William F. Rayburn, MD, MBA, FACOG, “The Obstetrician Gynecologist Workforce in the United States: Facts, Figures, and Implications, American Congress of Obstetricians and Gynecologists, 2011. Data on CNM/CMs is per AMCB available at http://www.amcbmidwife.org/about-amcb/annual-reports and 2014 National Population Projections, US Census Bureau, available at: https://www.census.gov/population/projections/files/summary/NP2014-T3.xls
“Maternal Care Providers” includes OB/GYNs (Fellows and Jr. Fellows), and CNMs/CMs.
Source: OB/GYN data are per private communication with ACOG and also William F. Rayburn, MD, MBA, FACOG, “The Obstetrician Gynecologist Workforce in the United States: Facts, Figures, and Implications, American Congress of Obstetricians and Gynecologists, 2011. Data on CNM/CMs is per AMCB available at http://www.amcbmidwife.org/about-amcb/annual-reports and 2014 National Population Projections, US Census Bureau, available at: https://www.census.gov/population/projections/files/summary/NP2014-T3.xls
William F. Rayburn, MD, MBA, FACOG, “The Obstetrician Gynecologist Workforce in the United States: Facts, Figures, and Implications, American Congress of Obstetricians and Gynecologists, 2011, Tables 1-4 and 2-1.
Accreditation Council for Graduate Medical Education, Years 2011-2014. See: http://www.acgme.org/acgmeweb/tabid/259/GraduateMedicalEducation/GraduateMedicalEducationDataResourceBook.aspx
American Midwifery Certification Board – See: http://www.amcbmidwife.org/docs/default-document-library/certificants-1971---present.pdf?sfvrsn=4
Source: William F. Rayburn, MD, MBA, FACOG, “The Obstetrician Gynecologist Workforce in the United States: Facts, Figures, and Implications, American Congress of Obstetricians and Gynecologists, 2011.
* 2014 Physician Specialty Data Book, AAMC Center for Workforce Studies, November 2014.
Source: 2009 AAMC Annual Meeting Presentation, available at: https://www.aamc.org/download/82844/data/annualaddress09.pdf
AAMC Press release, available at: https://www.aamc.org/newsroom/reporter/sept2011/260020/part-time.html
Source: William F. Rayburn, MD, MBA, FACOG, “The Obstetrician Gynecologist Workforce in the United States: Facts, Figures, and Implications, American Congress of Obstetricians and Gynecologists, 2011.
William F. Rayburn, MD, MBA, FACOG, “The Obstetrician Gynecologist Workforce in the United States: Facts, Figures, and Implications, American Congress of Obstetricians and Gynecologists, 2011. See specifically Tables 4-6 and 4-7.
See also: Rayburn, W., Gant, N., Gilstrap, L., Elwell, E., Williams, S., “Pursuit of accredited subspecialties by graduating residents in obstetrics and gynecology, 2000-2012,” Obstetrics & Gynecology, 2012, Vol. 120, pp. 619-625.
Source: William F. Rayburn, MD, MBA, FACOG, “The Obstetrician Gynecologist Workforce in the United States: Facts, Figures, and Implications, American Congress of Obstetricians and Gynecologists, 2011.
Source: Area Resource File. Slide originally created on 3/1/2014 by Kate Crawford, Birth by the Numbers (www.birthbythenumbers.org)
See also: “The Obstetrician Gynecologist Workforce in the United States, Facts, Figures, and Implications,” American Congress of Obstetricians and Gynecologists, 2011
Source: Area Resource File. Slide originally created on 3/1/2014 by Kate Crawford, Birth by the Numbers (www.birthbythenumbers.org)
Source: Area Resource File. Slide originally created on 3/1/2014 by Kate Crawford, Birth by the Numbers (www.birthbythenumbers.org)
1 Percentage derived from number of low risk women, shown in Table I of the technical notes here: http://www.cdc.gov/nchs/data/nvsr/nvsr63/nvsr63_06.pdf and from the total number of first time mothers, derived from http://www.cdc.gov/nchs/data_access/vitalstats/vitalstats_births.htm
2 See: http://www.nichd.nih.gov/health/topics/high-risk/conditioninfo/Pages/risk.aspx
3. ACOG Committee Opinion No. 549, January 2013
Jane Sandall, Hora Soltani, Simon Gates, Andrew Shennan, Declan Devane, “Midwife-led continuity models versus other models of care for childbearing women,” The Cochrane Collaboration, 2013.
Hatem M, Sandall J, Devane D, Soltani H, Gates S, “Midwife-led versus other models of care for childbearing women (Review),” The Cochrane Collaboration and published in The Cochrane Library 2009, Issue 3.
Meg Johantgen, PhD, RN a,*, Lily Fountain, MS, CNM, RN a, George Zangaro, PhD, RN b, Robin Newhouse, PhD, RN, NEA-BC a, Julie Stanik-Hutt, PhD, ACNP, CCNS, FAAN c, Kathleen White, PhD, RN, NEA-BC, FAAN, “Comparison of Labor and Delivery Care Provided by Certified Nurse-Midwives and Physicians: A Systematic Review: 1990 to 2008,” Women’s Health Issues, vol. 22, no. 1, 2012, pp. e73-e81.
Petra ten Hoope-Bender, Luc de Bernis, James Campbell, Soo Downe, Vincent Fauveau, Helga Fogstad, Caroline S E Homer, Holly Powell Kennedy, Zoe Matthews, Alison McFadden, Mary J Renfrew, Wim Van Lerberghe, “Improvement of maternal and newborn health through Midwifery,” www.thelancet.com Published online June 23, 2014 http://dx.doi.org/10.1016/S0140-6736(14)60930-2.
The Joint Statement of Practice Relations Between Obstetrician/Gynecologists and Certified Nurse-Midwives/Certified Midwives is available at: http://www.midwife.org/ACNM/files/ACNMLibraryData/UPLOADFILENAME/000000000224/ACNM.ACOG%20Joint%20Statement%203.30.11.pdf
* Numbers are as of 2015 and are provided by ACOG, AMCB and NARM.
** There were 3.93 million births in 2013. This figure assume 60% were normal pregnancies.
“Graduate Medical Education that Meets the Nation’s Health Needs,” Institute of Medicine, July 29, 2014. Available at: http://www.iom.edu/Reports/2014/Graduate-Medical-Education-That-Meets-the-Nations-Health-Needs.aspx
GNE Expenditures per Section 5509 of the Affordable Care Act
Nursing Workforce Development Expenditures per HRSA’s FY 2014 Appropriations
Medicare caps the number of residency positions it funds through DME/IME payments at the number of residents in existence in 1996. MedPAC estimated that in 2010 there were 85,228 DGME-funded residency positions. See: http://www.medpac.gov/documents/contractor-reports/sept13_residents_gme_contractor.pdf?sfvrsn=0. In 2014, there were 117,427 total residents in the U.S. (see: “Graduate Medical Education, 2013-2015,” JAMA, December 10, 2014, Volume 312, Number 22). Thus, in 2014 approximately 73% of residents were supported through Medicare DGME. The JAMA article reports that in 2014 there were a total of 5,028 OB/GYN residents. This slide estimates that 73% of those OB/GYN residents were funded through Medicare DGME. The precise would have to be obtained by surveying OB/GYN residency programs. The figure of $100,000 per year per OB/GYN resident in GME expenditures is from a presentation by Dr. John Jennings at ACNM’s 2015 annual meeting.
ACNM held discussions with staff at the University of Pennsylvania, which is one of five sites participating in the GNE demonstration and was informed that in 2014 they were able to add 4 SNM students to their program due to funding from the GNE demonstration. They also noted that they were paying their preceptors $15,000 per year, per student to provide clinical precepting. This is the basis of the numbers in this chart.
Number of midwifery students is per ACNM, 2014. The number of GNE funded midwifery positions is based on information directly reported to ACNM by the one midwifery education program participating in the GNE demonstration.
As of September 2014, the NHSC was supporting 1,154 students, 149 of whom were nurses or physician assistants. Nine of those 149 were certified nurse-midwife students. Eight hundred eighteen were medical students and 147 dental. As of September 2014, there were 9,242 clinicians who had completed their education and were working off their commitment to the NHSC for having received a scholarship or loan repayment. Of those, 143 were CNMs, 2,405 were physicians, 2,730 nurses or PAs, 2,630 mental and behavioral health specialists, and 1,308 dentists and dental hygienists. Source: HRSA’s 2016 Budget Justification, available at: http://www.hrsa.gov/about/budget/budgetjustification2016.pdf
In 2014, there were 9 student midwives being supported by NHSC scholarships and 143 CNMs working off a commitment to the NHSC due to having received a scholarship or loan repayment.
Source: Private communication between ACNM and HRSA and HRSA’s FY 2016 Budget Justification, available at: http://hrsa.gov/about/budget/budgetjustification2016.pdf
Data from Australia are 2005 figures and are from Tim Rowland (BSc), Dr. Deborah McLeod (BSc (Hons), PhD, DipPH) and Natalie Froese-Burns (BA (Hons), M.Econ), (“Comparative Study of Maternity Systems,” Malatest International, Nov. 2012, available at: http://www.health.govt.nz/publication/comparative-study-maternity-systems
Data for Canada, Denmark, Finland, France, Germany, Japan, Korea, Singapore, UK are 2009 figures from Narumi Eguchi, “Do We Have Enough Obstetricians? – A survey of the Japan Medical Association in 15 countries,” JMAJ, May/June 2009, vol. 52, no. 3, pp. 150-157.
Data for Austria, Belgium, Greece, Italy, Luxembourg, Netherlands, Portugal, Spain, Sweden are 2000 figures and are from J.K. Emons, M.I.J. Luiten, “Midwifery in Europe: An Inventory in fifteen EU-member states,” Deloitete & Touche, 2001, available at: http://www.deloitte.nl/downloads/documents/website_deloitte/GZpublVerloskundeinEuropaRapport.pdf
Data for the US are from 2013 and are from the American Midwifery Certification Board (see: http://www.amcbmidwife.org/docs/default-document-library/chart-for-number-of-cnm-cm-by-state---february-2014-present.pdf?sfvrsn=0) and the Association of American Medical Colleges (see: https://members.aamc.org/eweb/upload/14-086%20Specialty%20Databook%202014_711.pdf)
J.K. Emons, M.I.J. Luiten, “Midwifery in Europe: An inventory in fifteen EU-member states, The European Midwives Liaison Committee, study by Deloitte & Touche, 2001. Available at: http://www.deloitte.nl/downloads/documents/website_deloitte/GZpublVerloskundeinEuropaRapport.pdf Note that this source reports a range of 70% - 75% midwife attended births in both Denmark and France. The graph above takes a midpoint from that range.
Data on Iceland provided in private communication from Hildur Kristjánsdóttir, Chief midwifery officer, Division of supervision and quality, Directorate of Health
Maternal mortality data are from “Trends in Maternal Mortality: 1990 – 2013,” WHO, UNICEF, UNFPA, The World Bank and the United Nations Population Division, 2014. Available at: http://apps.who.int/iris/bitstream/10665/112682/2/9789241507226_eng.pdf?ua=1
Infant mortality data are from “World Health Statistics, 2014,” World Health Organization. Available at: http://apps.who.int/iris/bitstream/10665/112738/1/9789240692671_eng.pdf
Source: CDC/NCHS, National Vital Statistics System.
See: “NPP Utilization in the Future of US Healthcare,” Medical Group Management Association, March 2014, available at: https://www.mgma.com/Libraries/Assets/Practice%20Resources/NPPsFutureHealthcare-final.pdf
AAMC Tuition and Student Fees Report, 2014-2015. Figure includes tuition, fees and student health insurance. Available at: https://services.aamc.org/tsfreports/select.cfm?year_of_study=2015 These figures were multiplied by four. Actual costs will likely be higher because these figures were not inflated for each of the four years.
Midwifery education costs from Kathleen Fagerlund, CRNA, PhD, and Elaine Germano, CNM, DrPH, “The Costs and Benefits of Nurse-Midwifery Education: Model and Application,” Journal of Midwifery and Women’s Health, Vol. 54, No. 5, September/October 2009, pp. 341-350. This article reports 2008 dollars for tuition, fees, books and supplies which were inflated to 2015 dollars using an inflationary rate of 2.8% per year, per the inflationary rate for public college tuition/fees from the College Board, available at: http://trends.collegeboard.org/college-pricing/figures-tables/average-rates-growth-published-charges-decade
* Elaine Germano, CNM, DrPH, et al., “Factors that Influence Midwives to Serve as Preceptors: An American College of Nurse-Midwives Survey,” Journal of Midwifery & Women’s Health,” Vol. 59, No. 2, March/April 2014, pp. 167-175.
* Elaine Germano, CNM, DrPH, et al., “Factors that Influence Midwives to Serve as Preceptors: An American College of Nurse-Midwives Survey,” Journal of Midwifery & Women’s Health,” Vol. 59, No. 2, March/April 2014, pp. 167-175.
* AAMC's 2014 Physician Specialty Data Book, indicates there were 38,457 OB/GYNs in active patient care in that year. ACOG data indicate 77% of actively practicing OB/GYNs are attending births. So assume there were 29,611 OB/GYNs actively attending births in 2014. CDC preliminary 2014 data indicate there were 3,985,924 births. In 2013, physicians attended 90.43% of births, so assume that in 2014, they attended 3,604,348 births. Assuming that the 29,611 OB/GYNs attending births accounted for the entire universe of physicians attending births (known to be incorrect, but it will inflate the average number of per-physician attended births), this yields an average of 122 births per OB/GYN.
** ACNM’s benchmark data from 2013 indicate that actively practicing CNMs/CMs attended an average of 70 births apiece.
* See Appendix for studies demonstrating cesarean rate by provider type in risk adjusted populations..
** Assumes per CDC data that Medicaid covers 43.7% of births and others are paid at commercial rates. Total costs based on Truven Health Analytics study results, inflated to 2015 dollars per the MEI (see Appendix).
Source: HRSA’s FY 2016 Budget Justification, available at: http://hrsa.gov/about/budget/budgetjustification2016.pdf
See: http://innovation.cms.gov/initiatives/gne/
For more detail, see: http://gru.edu/ahec/ptip/faq_ptip.php
“Precepting” under this program consists of the hours spent by a student at the preceptor site.
The ACGME Program Requirements for Graduate Medical Education in Obstetrics and Gynecology specify that CNMs may serve as faculty in these programs and supervise interns/residents. See II.B.4 available at: https://www.acgme.org/acgmeweb/Portals/0/PFAssets/ProgramRequirements/220_obstetrics_and_gynecology_2016.pdf
Sources
Study 1 - Chambliss LR, Daly C, Medearis AL, Ames M, Kayne M, Paul R, “The role of selection bias in comparing cesarean birth rates between physician and midwifery management,” Obstetrics and Gynecology, August 1992, 80(2):161-5.
Study 2- Butler, J., Abrams, B., Parker, J., Roberts, J. M., Laros, R. K., Jr., “Supportive nurse-midwife care is associated with a reduced incidence of cesarean section. American Journal of Obstetrics and Gynecology, 1993, vol. 168, 1407–1413.
Study 3 - Hueston, W. J., & Rudy, M. “A comparison of labor and delivery management between nurse midwives and family physicians,” The Journal of Family Practice, 1993, Vol. 37, pp. 449–454.
Study 4 - Davis, L. G., Riedmann, G. L., Sapiro, M., Minogue, J. P., Kazer, R. R. “Cesarean section rates in low-risk private patients managed by certified nurse-midwives and obstetricians,” 1994, Journal of Nurse-Midwifery, Vol. 39, pp. 91–97.
Study 5 - Oakley, D., Murtland, T., Mayes, F., Hayashi, R., Petersen, B. A., Rorie, C., et al., “Processes of care: Comparisons of certified nurse-midwives and obstetricians,” Journal of Nurse-Midwifery, 1995, Vol. 40, pp. 399–409.
Study 6 - Rosenblatt, R. A., Dobie, S. A., Hart, L. G., Schneeweiss, R., Gould, D., Raine, T. R., et al., “Interspecialty differences in the obstetric care of low-risk women,” American Journal of Public Health, 1997, Vol. 87, pp. 344–351.
Study 7 - Cragin, L. E., “Comparisons of care by nurse-midwives and obstetricians: birth outcomes for moderate risk women.” Unpublished PhD Dissertation/Thesis, University of California at San Francisco, San Francisco, CA, 2002.
Study 8 - Jackson, D., Lang, J., Swartz, W., Ganiats, T., Fullerton, J., Ecker, J., Nguyen, U., "Outcomes, Safety, and Resource Utilization in a Collaborative Care Birth Center Program Compared with Traditional Physician-Based Perinatal Care," American Journal of Public Health, 2003, Vol. 93, pp. 999-1006.
Study 9 - Cragin, L., & Kennedy, H. P. Linking obstetric and midwifery practice with optimal outcomes. Journal of Obstetric, Gynecologic, and Neonatal Nursing, 2006, Vol. 35, pp. 779–785.
Study 10 - Cawthon, L., "Hospital Births* to Women With Medicaid‐paid Prenatal Care for Live Deliveries 2010‐2012. With and Without Primary Prenatal Care by a Certified Nurse Midwife," Unpublished study using State of Washington's First Steps Database, December 10, 2013. Copy in possession of ACNM.
Study 11 - Altman, M. R., "Exploration of Nurse-Midwifery Care for Childbirth," Unpublished PhD Dissertation, Washington State University College of Nursing, 2015.
ACNM’s benchmarking data are available at: http://www.midwife.org/Benchmarking-Project-Results
Methods
Total population and incidence figures drawn from studies 1, 3, 4, 8, and 11.
“The Cost of Having a Baby in the United States,” Truven Health Analytics Marketscan® Study, January 2013. Costs and charges associated with newborn care include those incurred through the first three months of life.
