Midwives and Ob/Gyns: A Quest for Collaboration in Obstetric Care

Aaron Caughey, MD, PhD; Tekoa L. King, CNM, MPH


June 21, 2012

In This Article

Editor's Note:

In March 2011, the American College of Nurse-Midwives (ACNM) and the American College of Obstetricians and Gynecologists (ACOG) released a new revision of the Joint Statement of Practice Relations Between Obstetrician-Gynecologists and Certified Nurse-Midwives/Certified Midwives.[1] (For Medscape Medical News coverage, see A Call for Greater Cooperation Between Ob-Gyns and Midwives .) This landmark publication is part of an ongoing initiative that emphasizes fostering and enhancing collaborative practice between certified nurse-midwives (CNMs)/certified midwives (CMs) and obstetrician-gynecologists (ob/gyns). Both ACNM and ACOG have agreed to support evidence-based practice and promote the highest standards for education, national professional certification, and recertification, among other shared commitments, to meet the goals outlined in the Joint Statement.

Aaron B Caughey, MD, PhD, Director of the Center for Women's Health and Professor and Chair of the Department of Obstetrics and Gynecology at Oregon Health and Science University in Portland, and Tekoa L. King, CNM, MPH, Clinical Professor at the Department of Obstetrics, Gynecology, and Reproductive Services at the University of California, San Francisco, agreed to discuss with Medscape how this monumental document will affect how ob/gyns and CNMs/CMs work together and thereby influence the state of maternity care and other women's health services in the United States.

Ob/Gyn and Midwife Interactions: High Points and Challenges

Medscape: Ob/Gyns and CNMs/CMs have a longstanding professional relationship in women's healthcare. From the perspectives of an ob/gyn and a CNM, what have been the noteworthy high points and challenges throughout the history of the interactions between these 2 professions?

Tekoa King, CNM, MPH: Thank you for the opportunity to discuss this topic. Nurse-midwifery was introduced [in the United States] in 1925 to care for a rural population in eastern Kentucky that did not have access to medical care. The model established in Leslie County, Kentucky, became the template for how CNMs/CMs and ob/gyns collaborate today. In short, CNMs/CMs provide primary care, normal obstetric care, and risk assessment. Women at elevated risk for obstetric complications or who have coexisting medical conditions are referred to partner ob/gyns for care.

From my perspective as a CNM, the high points of this relationship are the rewards of working in a well-functioning team. Interdisciplinary teams have distinct benefits for patients and clinicians. Women are cared for by a healthcare team, which includes experts in normal pregnancy and birth as well as experts in complications that may occur. Thus, patient satisfaction is improved. The CNMs/CMs and ob/gyns share their expertise and viewpoints, which allows each provider to learn and expand his or her professional skills. CNMs/CMs and ob/gyns who collaborate also report high levels of work satisfaction.

Challenges can occur in the following situations:

  • The 2 professions financially compete for patients in 1 geographic area; and

  • The CNM/CM is not comfortable with the clinical skills of the ob/gyn or vice versa.

When 1 of these 2 scenarios develops, the situation becomes a professional "turf war" that usually results in suppressing the expansion of midwifery in that setting.

Aaron Caughey, MD, PhD: Tekoa makes some valid points about the relationships between ob/gyns and CNMs/CMs in the United States.

Elsewhere in the world, these relationships are a little clearer and better defined. Throughout a number of European countries and Australia and New Zealand, midwives provide much of the basic obstetric care, including most of the labor support and management that in this country is provided by labor and delivery nurses.

This means that ob/gyns rely on highly skilled midwives to provide the bulk of obstetric care, reserving the ob/gyns for high-risk conditions; management of medical complications; and operative obstetrics, including operative vaginal and cesarean delivery. In those system designs, competition does not exist between the 2 types of providers because they rely on each other.

In the United States, midwifery made strides in the 1970s, providing a viable alternative to ob/gyns in many parts of the country. As a consequence, physicians viewed midwives as competitors. When that occurs, as Tekoa noted, disagreements can arise about management issues, creating friction between the groups.

I wondered recently why no midwives were available at a local hospital when I know that a group of midwives in fact works in the community but delivers babies at a different hospital. It turns out that this group [of midwives] had been affiliated with the original hospital in the early 1990s, but a group of physicians who had agreed to back them up at the hospital stopped doing so. The midwives couldn't identify anyone else who would serve in this capacity, so they had to stop delivering at that hospital. Luckily for the patients, physicians at the second hospital were happy to provide backup, so the patient volume shifted to this second hospital, where it remains today. This means that more than 400 women in the first community drive 20-30 minutes to deliver at the second hospital instead of 5-10 minutes to the first hospital, which is unfortunate and inefficient.

The scope-of-practice issue is interesting. Physicians who serve in a "back-up" role to midwives typically want that scope of practice to be very tight, such that anything that strays outside of normal labor and delivery is referred. However, when physicians and midwives work together, the physicians often expand the midwives' role to providing a wider range of care. I practiced in a group in which the midwives did everything except operative deliveries and medical management of the sickest patients. They provided the labor and delivery care for preterm patients and women with diabetes or preeclampsia. In that setting, having the physician deliver the baby offers no medical or financial advantage as long as everyone has agreed on the management plan. However, many midwives would be uncomfortable providing care for such high-risk patients on their own. But in a team setting, the physicians can focus on the medical issues and the midwives can focus on the issues related to optimizing the birth experience.

Finally, because of the financial competition and lack of experience working with midwives, many physicians are leery of having them at their hospitals or in their communities. This is too bad and is usually related to a lack of experience [working with midwives]. I was trained by midwives in Boston, Massachusetts, and worked with midwives in the Bay Area [in San Francisco, California] in a variety of settings. I continue to work with midwives now in Oregon. If asked to design a system of care for pregnant women, my optimal model would include both midwives and physicians. I believe that both healthcare professionals have a place in the provision of obstetrics.

Medscape: Are the shared commitments of the Joint Statement on target and feasible or realistic for ob/gyns and CNMs/CMs across various healthcare settings?

Ms. King: In short, yes. The key component of the Joint Statement is the affirmation that both ob/gyns and CNMs/CMs are licensed, independent providers and that they work together best within a healthcare system that fosters collaboration.

Women get the best healthcare when they choose their primary care providers and have seamless access to other levels of care as needed. The Joint Statement is on target in promoting this model of care.

Successful collaboration is feasible and realistic in any healthcare setting as long as both CNMs/CMs and ob/gyns want to collaborate professionally.

Dr. Caughey: I agree with Tekoa on this issue. Both economic and philosophical issues influence the feasibility of a shared commitment across all practice settings.

The reality is that ob/gyns can be threatened economically by midwives, particularly in smaller communities with fewer patients. Over the past several years, we have seen the number of births in the United States decline by as much as 10%. That means that if the population of obstetric providers has been relatively stable over the same timeframe, then each provider is doing 10% fewer deliveries than they were doing just 3-4 years ago. Because deliveries are often squeezed into a clinician's schedule, they can't make up that 10% by doing other work. So, in a private setting, where your earnings equal your revenue minus your expenses, a decline in revenue is inevitable.

If an ob/gyn is in a setting with a low-to-moderate patient volume, it would be threatening to have a midwife come into that market because the midwife is going to take a certain proportion of that volume away, simply by virtue of being a midwife. If the midwife has to work with a physician back-up, [the physician can] agree -- or not -- to sign on as the back-up. I have heard of communities where no physician would agree to [this arrangement]. The best thing in that setting, then, would be for the physician and the midwife to consider going into practice together.

Philosophical issues may exist, as well. I find that midwives are taught, fundamentally, that birth is a natural process that goes well in most cases. Obstetricians, [on the other hand,] are taught the medical model of disease, treating everything in pregnancy as if it were about to go wrong. These fundamental philosophical differences can lead to misunderstandings and confusion between physicians and midwives on issues of medical management, counseling, and labor care.


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