Are CNMs independent of OBs or not?

beckinben, CNM · Jun 8, 2007

I've gotten some conflicting info here. Somebody told me that CNMs are required by law to have OB collaboration, somebody else told me that CNMs are totally independent of doctors and have their own practice which is totally separate?

CNMs are required by the standards of practice published by the ACNM to have some sort of MD collaboration. The wording in the document is this:

The midwife:

Demonstrates a safe mechanism for obtaining medical consultation, collaboration, and referral.

This does not have to be an OB, by the way. Some midwives have collaborative arrangements with family practice doctors or with hospitals. Note that ACNM actively opposes requiring midwives to have written collaborative agreements. When you say some midwives have independent practices, yes, I know of some, but they all have some means of getting help when they need it. Just like family practice docs refer people to cardiologists or endocrinologists. The issue is how formal do those arrangements have to be and do they need to be in writing. It can be a liability issue for an OB to have a written agreement with a CNM.

ACOG and ACNM have a joint statement on this topic and you can read it here - http://www.midwife.org/siteFiles/position/Joint_Statement_05.pdf

However,

I imagine the laws vary by state, but whats typical for most states? Are CNMs required to collaborate with OBs or not?

Yes, state laws vary widely, and can (and are) much more restrictive than the ACNM/ACOG standards. I have midwifery licenses in two states. One requires me to have a written supervisory agreement with a doctor, in which we lay out exactly how he is going to supervise me. This, IMO, is way beyond collaboration, but it is how it is in this state. The other state only requires a collaborative agreement for prescriptive authority. If you don't want to write scripts, you can have a pretty independent practice. The typical arrangement seems to be a written collaborative agreement.

If CNMs are not required to collaborate or be supervised by MDs, then why do so many CNMs choose to work in hospital settings? It seems to defeat the purpose to me.

Why do CNMs choose to work in hospitals? Well, the vast, vast majority of women still choose to deliver there, and we would be shooting ourselves in the foot to ignore that population. Also, and this is why I work in the hospital, I feel that women in the hospital have more need for midwives. I'm not sure what you feel the purpose of midwives are, but I feel I am here to educate and support women in making informed choices about their body and their birth. And that, to me, seems to be more needed in the hospital setting.

Becki

platon20 · Jun 8, 2007

Yeah but delivering a baby in a hospital is 10 times more expensive than doing it at home. Home deliveries require you to pay only for the CNMs services, when you go to a birthing center or hospital the costs get jacked up many times over because now you have to pay hospital fees and all other kinds of ridiculous nonsense.

If a woman insists on having a baby in a hospital setting, thats fine, but I wonder how many CNMs really offer home services. Do most CNMs do both hospital-based AND home deliveries or do they just stay at the hospital/birth center?

Having a baby at a hospital setting, regardless of whether its a CNM or OB delivery is an unnecessary waste of money unless its a high risk pregnancy. You are paying for extra stuff that you dont need.

platon20 · Jun 8, 2007

Just like family practice docs refer people to cardiologists or endocrinologists.

I dont think this is the same thing as a CNM-OB relationship though. From what you have told me, it seems like an OB has to agree AHEAD OF TIME to work with a particular CNM.

beckinben, CNM · Jun 8, 2007

If a woman insists on having a baby in a hospital setting, thats fine, but I wonder how many CNMs really offer home services. Do most CNMs do both hospital-based AND home deliveries or do they just stay at the hospital/birth center?
Having a baby at a hospital setting, regardless of whether its a CNM or OB delivery is an unnecessary waste of money unless its a high risk pregnancy. You are paying for extra stuff that you dont need.

97% of all CNM births are done in the hospital. It is rare to find a CNM that does both hospital and home births, mostly because of malpractice insurance reasons and hospital credentialing issues.

Many (most) women do "insist" on giving birth in the hospital. Some do it because they honestly have no idea how to go about having a home birth. Some do it because they want the epidural or the c-section. Some do it because their partner is not comfortable with a home birth. Some do it because they want the "extra stuff" - they want the break from their other children, they want room service and a big tub and a nursery to put the baby in at night so they can sleep. Many do it because they believe that hospital birth is safer than home birth. After all, ACOG says it is so it must be true (sarcasm there). They want to feel that if something goes wrong, the baby can get out faster. Not that I believe it's always the case, but this is what I hear from women.

Some women are forced into the hospital because that is what their insurance will cover. Insurance coverage for home birth is very spotty, and requires a great deal of effort both by the woman and the midwife to get payment, when payment is even made. And many women can't or won't pay thousands out of pocket for a home birth. Plus, in some states, including one I practice in, I am not legally allowed to attend a home birth. Period. So if women want to deliver at home, they have to do it alone.

Here's some other reasons why CNMs choose hospital work. It often offers shift work because you can be in a group with a number of other providers, either other CNMs or OBs. Being on call all the time is exhausting, and can make for a pretty crappy personal life. Hospitals and group practices also have a much easier time affording - and getting - malpractice insurance. Many home birth CNMs cannot get or cannot afford malpractice insurance. Some stop practicing, and some go without and hope not to be sued. These are the bravest women, IMO, and I love hearing their stories. They inspire me.

What you say is true, but it's what would be true in an ideal world. What I'm describing is the real world (a simplified version, to be honest - there are so many factors that play into the real state of midwifery today that I could write a book and not explain it all). And I think there are two things I can do. I can do home births (in states where that is legal) and help the women that choose that path, or I can stay in the hospital, and make the small changes - like promoting evidence-based care - that could someday lead to bigger changes. What you're describing will require a real culture change in the US, and that change isn't going to come all at once.

beckinben, CNM · Jun 8, 2007

I dont think this is the same thing as a CNM-OB relationship though. From what you have told me, it seems like an OB has to agree AHEAD OF TIME to work with a particular CNM.

In some states, yes. In some states, no. In states with true independent practice, I could see my own patients, and if there was a problem, refer them to an OB and still be practicing in accordance with ACNM standards. An OB would not have to agree to this in advance, just like cardiologists do not have to have written agreements in advance with FPs to take their referrals. Although the polite thing to do is to have a relationship with an OB or a FP that does obstetrics in advance to make the transition easier.

This scenario is the ideal, obviously, but does actually exist in some places. Some OBs actually like having collaborative relationships with CNMs - they get referrals and therefore money from these relationships.

Stacey03 · Jun 11, 2007

I am beginning nursing school this fall with the goal of becoming a CNM that does homebirth in Indiana because CPMs are not legally recognized. Does anyone know how restrictive the laws in Indiana are? I know we have a couple of CNMs doing homebirths.

beckinben, CNM · Jun 12, 2007

I am beginning nursing school this fall with the goal of becoming a CNM that does homebirth in Indiana because CPMs are not legally recognized. Does anyone know how restrictive the laws in Indiana are? I know we have a couple of CNMs doing homebirths.

Here's a place to start. This link - http://www.mana.org/laws.html - will show you the laws relating to midwifery for states where specific laws exist.

platon20 · Jun 13, 2007

I dont understand why insurance companies wont pay for home births. They would save a TON OF MONEY by doing this option instead of sending everyone to the hospital.

If you have a CNM doing a home delivery, the entire cost is just based on equipment/drugs and the CNMs salary, which I expect might be a couple hundred dollars.

When you send a woman to the hospital, the CNM still gets paid maybe $200 for delivering the baby but now all the bogus hospital charges get kicked in and your total bill is easily $5,000 or higher, and NONE of that is going to actually cover the cost of doing the procedure.

Its absolutely ridiculous, the lawyers must be filing lawsuits left and right on home deliveries.

beckinben, CNM · Jun 13, 2007

I dont understand why insurance companies wont pay for home births. They would save a TON OF MONEY by doing this option instead of sending everyone to the hospital.
If you have a CNM doing a home delivery, the entire cost is just based on equipment/drugs and the CNMs salary, which I expect might be a couple hundred dollars.
When you send a woman to the hospital, the CNM still gets paid maybe $200 for delivering the baby but now all the bogus hospital charges get kicked in and your total bill is easily $5,000 or higher, and NONE of that is going to actually cover the cost of doing the procedure.
Its absolutely ridiculous, the lawyers must be filing lawsuits left and right on home deliveries.

Sorry, but my salary is more than $200, and I am worth every penny. Maybe a doc who walks in as the head crowns and catches and walks out 15 minutes later deserves $200, but I don't.

I think I'll be leaving this thread - to say a CNM is only worth $200 is a little too much like CNM-bashing to me. :nono:

platon20 · Jun 15, 2007

Fine then make it $500, or $1000, or $10,000 per delivery. Thats not hte point and I really dont care what CNMs make for each delivery.

The point is that WHATEVER CNMs make, whether its $1 per delivery or $10,000 per delivery is going to be MUCH MUCH cheaper than what it costs for a CNM-delivery at a birth center or major hospital.

beckinben, CNM · Jun 15, 2007

Fine then make it $500, or $1000, or $10,000 per delivery. Thats not hte point and I really dont care what CNMs make for each delivery.
The point is that WHATEVER CNMs make, whether its $1 per delivery or $10,000 per delivery is going to be MUCH MUCH cheaper than what it costs for a CNM-delivery at a birth center or major hospital.

I may have overreacted in my response, but you should know that your arguments would have more credibility (at least for me) if you had a more realistic view of the costs of health care. And your arguments would also have a little more credibility if the overall tone did not come across as quite so argumentative and closed-minded. I'm giving you the benefit of the doubt and assuming that your questions have in fact been to gain information or perspective, and not just to bash hospital CNMs.

Obviously, hospital deliveries cost more than home births. No one is arguing with you on that one. The difference in costs is probably not as great as I think you think it is. Obviously it varies based on where you live, but where I used to live, an unmedicated lady partsl hospital birth costs about twice what your average home birth midwife charges. Birth center (free-standing birth center) births are much more comparable in cost to home births than hospital births.

Where I am now, there ARE no legal assisted home births. So even if I bought into your message that CNMs should quit doing hospital births because it is a ripoff and start doing home births en mass, that is just not going to happen. The laws have to be changed first. And until they are, I am going to keep doing hospital births, keep trying to change the laws, keep trying to make hospital birth better for women, keep feeding my family, and keep my *&% out of jail. I'm not going to do anyone any good in jail (unlike Paris ).

What I am trying to help you understand is the gulf that exists between the ideal - which is what you are presenting - and the reality of the world today - which is what I am trying to explain to you. MY point is that you can argue and complain about the current state of things until you are blue in the face, but nothing is going to change until people stop complaining without offering feasible solutions and start MAKING the changes.

Changing the culture of birth is not going to happen overnight. One step to making this change COULD and SHOULD be to have CNMs become more prevalent in the hospital setting, as a transition step to having midwifery (not just CNM) care as a whole - encompassing and promoting the woman's CHOICE to deliver at home - become more widely accepted in our culture. Then, when women start seeing that home birth is, in fact, a safe alternative for low risk women, and when insurance companies see that midwives do in fact save them money in the hospital setting and could save them even more money outside the hospital, home birth may become a more feasible choice for more women. This is going to take time, if it happens at all. Giving up and leaving the hospital is probably the worst thing that CNMs could do, though.

You wanted to know why CNMs keep working in the hospital. Everything I've said - that is why.