Certified Nurse-Midwives Improve Pregnancy Outcomes

Theresa Hagen, CNM

In an effort to fill the obstetrician shortage, 1 health system has a collaborative care model led by certified nurse-midwives which improved overall outcomes.

Mayo Clinic Health System — Franciscan Healthcare in La Crosse, Wisconsin, implemented the collaborative care model to address the lack of obstetricians. Health system representatives reported that implementing the care model in 2014 has led to a 4% decrease in admissions to the neonatal intensive care unit (ICU) and reduced the rate of cesarean section birth and vaginal operative deliveries.

There is an increasing shortage of obstetricians due to unpredictable work hours, Theresa Hagen, CNM, and Laura Harkness, CNM, MSN, investigators from Mayo Clinic Health System — Franciscan Healthcare, said in an interview with HCPLive®. Obstetricians often become quite fatigues and face 1 of the highest rates of burnout of any specialty.

New and innovative approaches are needed to serve the needs of the patient and increase collaboration.

At the health system, patients schedule a visit for prenatal laboratory tests and choose their primary obstetric provider and set up their first prenatal visit. Patients also learn about the collaborative care model and, if they continue to be at low to moderate risk based on American College of Nurse-Midwives criteria, a midwife will manager her during antepartum, intrapartum, and postpartum. The patient has the choice to participate in the model or choose their specific obstetric provider instead.

The collaborative model ensured a certified nurse-midwife was in the hospital around the clock and that generalist obstetricians were on call when needed.

Mayo Clinic Health System reported several positive outcomes from the new care model.

The primary cesarean birth rate was 26% (285 primary cesarean sections among 665 eligible patients) in 2012. After implementation of the collaborative model, it decreased to 15% (240 primary cesarean sections among 608 eligible patients) through 2017.

Vaginal operative deliveries decreased from 5.9% (57 operative deliveries among 974 live births) in 2012 to 1.3% (11 operative deliveries among 846 live births) by 2017. Neonatal ICU admissions also saw a decrease from 14.5% (145 admissions among 974 live births) in 2012 to 10.9% (92 admissions among 846 live births) by the end of 2017.

The collaborative care model also resulted in a shorter length of stay in the hospital for new parents, Hagen and Harkness said.

Investigators used Press Ganey scores to assess the patients’ experiences with the nurse-midwives. Communication with providers was reported at 97% top-box score as of 2017. Patients reported the listening of their provider at 98% top-box score and that their provider explained things in a digestible manner at a 96% top-box score.

Providers also took into account the patient’s preference 99% of the time. Responsiveness also achieved a top-box score of 99%.

An email survey for the obstetricians and certified nurse-midwives revealed positive staff satisfaction with the new collaborative care model. A majority of certified nurse-midwives (85%) reported high satisfaction, while the obstetricians reported 50% high satisfaction, 25% satisfaction, and 25% neutral or poor satisfaction.

The certified nurse-midwives likely reported higher satisfaction than obstetricians because the midwives would have a 24-hour shift to stay with the patient rather than 8 or 12, Hagen and Harkness said. Obstetricians could be out and then have to get called back to the hospital.

For other health systems, a collaborative care model would require enough midwives to sustain and see improved outcomes, they said. The model can be cost-effective because in an obstetrician-laborist model, you would need 1000 deliveries per year to break even financially, and midwives cost less to an institution than obstetricians.

The study, “Midwife Laborist Model in a Collaborative Community Practice,” was published online in Mayo Clinic Proceedings: Innovations, Quality & Outcomes.