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The document discusses trends in the US maternity care workforce that have led to an imbalance between providers trained to care for higher risk vs normal pregnancies. As the population of women grows and more pursue subspecialties, the number of OB/GYNs has remained flat while demand increases. Midwives (CNMs/CMs) are well-suited to care for the majority of low-moderate risk pregnancies but public funding has disproportionately supported physician residencies over midwifery education. As a result, the workforce structure does not match the needs of the patient population.

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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 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 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.
Patient Needs
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.
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.
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.
Workforce Demographics
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.
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.
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.
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.
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.
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.
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.
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.
Workforce Maldistribution Compounding the Problem
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.
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.
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.
Patient Population vs. Workforce Structure
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.
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
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.
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 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.
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
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.
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.
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.
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.
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
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.
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 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.
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.
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.
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.
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 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).
What Can be Done to Increase the Supply of CNMs/CMs?
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 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 $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.
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.
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.
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 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
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%
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.

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MaternityCareWorkforce-11-18-15.pptx

  • 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

  • #6: US Census Bureau: https://www.census.gov/population/projections/data/national/2014/downloadablefiles.html
  • #7: US Census Bureau: https://www.census.gov/population/projections/data/national/2014/downloadablefiles.html
  • #8: Source: http://hcupnet.ahrq.gov/HCUPnet.jsp Last accessed 4/7/15.
  • #10: “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
  • #11: “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
  • #12: 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
  • #13: 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.
  • #14: 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
  • #15: 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.
  • #16: 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.
  • #17: 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.
  • #19: 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
  • #20: Source: Area Resource File. Slide originally created on 3/1/2014 by Kate Crawford, Birth by the Numbers (www.birthbythenumbers.org)
  • #21: Source: Area Resource File. Slide originally created on 3/1/2014 by Kate Crawford, Birth by the Numbers (www.birthbythenumbers.org)
  • #23: 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
  • #26: 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.
  • #27: 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
  • #28: * 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.
  • #29: “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
  • #30: 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.
  • #31: 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
  • #32: 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)
  • #33: 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
  • #34: Source: CDC/NCHS, National Vital Statistics System.
  • #36: 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
  • #37: 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
  • #38: * 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.
  • #39: * 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.
  • #40: * 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.
  • #41: * 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).
  • #45: Source: HRSA’s FY 2016 Budget Justification, available at: http://hrsa.gov/about/budget/budgetjustification2016.pdf
  • #46: See: http://innovation.cms.gov/initiatives/gne/
  • #47: 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.
  • #48: 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
  • #51: 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.
  • #52: “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.