263Preparing the Workforce
BARBARA A. ANDERSON, LINDA J. COLE, AND JESSE S. BUSHMAN
Upon completion of this chapter, the reader will be able to:
1. Discuss the global and national workforce shortage of qualified midwives
2. Explain the concept of task shifting as it applies to freestanding birth centers
3. Identify three key strategies for preparing the midwifery workforce for practice in birth centers
CURRENT STATE OF THE MATERNAL CHILD WORKFORCE
A functional health care system is comprised of fluid interactions among all the components (Riley, 2016). Building capacity for these interactions is dependent upon a sufficient and appropriately distributed workforce (Fullerton & Anderson, 2017). Currently, one of the most critical issues facing health care systems globally, including the United States, is the inadequate number and maldistribution of the health care workforce (World Health Organization [WHO], 2015a).
Maternal and child health is particularly vulnerable to the large gap in health care providers, driving the need for adequate number and appropriate distribution of the midwifery workforce across the globe, collaboration among providers of varying skill levels, and accessible, safe venues for birth. Although the highest maternal mortality still remains in 264Sub-Saharan Africa (Zureick-Brown et al., 2013), the United States has a shocking number of maternal deaths given its level of economic development. In the United States, maternal mortality has risen rapidly between 1990 and 2013 (Kassebaum et al., 2014). Other countries, including both high- and low-resource nations, have seen appreciable declines. The United States now ranks 60th (out of 180 nations) in maternal mortality, the highest among developed countries (Kassebaum et al., 2014).
The 2014 Lancet series on midwifery focused on the potential impact of midwifery services on reducing maternal and newborn mortality worldwide. Funded by the Gates Foundation, this report brought attention to the critical contribution that midwives make in improving the health of women and children globally. Examining care needs across all settings, the authors identified more than 50 short-, medium-, and long-term goals to improve the health of this population. This framework of quality care by midwives who are properly educated, trained, licensed, and regulated has been shown to decrease maternal mortality, improve outcomes, and decrease cost. These findings were applicable to high- and lower income countries and settings (Renfrew et al., 2014). Future maternal child workforce development planners should take these findings into consideration and choose to focus on the expansion of midwifery in those plans.
Authors of another article in the Lancet series reported finding that 83% of maternal deaths, stillbirths, and neonatal deaths worldwide would be prevented with the scaling up of the midwifery workforce. It was only when specialists were removed from the primary care of women and babies, and instead positioned within a system to accept referrals and transfers from midwives of women who need their services, that these improvements in outcomes could be observed (Homer et al., 2014). Similarly, freestanding birth centers in the United States, positioned in communities within integrated health systems, may improve health outcomes and serve as clinical sites for midwives and student midwives to learn to practice in this needed practice model.
The American College of Nurse-Midwives (ACNM) and the Accreditation Commission for Midwifery Education (ACME) published a joint statement in 2015 pointing to the global pattern of midwifery as the default profession caring for women anticipating normal birth, the extreme variance seen in this pattern in the United States, and the projected forecast by the U.S. Bureau of Labor Statistics for 31% growth in the market for midwifery care from 2012 to 2022. In a 7-year span between 2007 and 2014, the number of graduated certified nurse-midwives (CNMs) and certified midwives (CMs) approximately doubled, not due to an expansion in the 265number of educational programs for midwives but an increasing number of students in certain programs (ACNM & ACME, 2015).
The Strong Start for Mothers and Newborns Initiative grants, under the auspices of the Centers for Medicare and Medicaid Services (CMS), have provided impetus for midwifery practice, specifically within the context of birth center care (Alliman, Jolles, & Summers, 2015; American Association of Birth Centers [AABC], 2013). (See Chapter 9 for further discussion of the Strong Start program.) Opportunity for the advancement of midwifery within the venue of the birth center has never been greater. Preparing the midwifery workforce for the anticipated growth in freestanding birth centers is the challenge. A sufficient number of midwives must be educated and prepared for employment in this expanding care model.
U.S. Maternity Care Provider Balance
In the U.S. context, there are many more obstetrician/gynecologists than midwives; therefore, it is important to understand trends in the OB/GYN workforce when considering women’s access to a skilled maternity care provider and the anticipated role midwives will play going forward. The number of medical school graduates in the United States entering an OB/GYN residency has remained basically flat, at about 1,200 per year, for the past 30 years. In addition, the proportion of first-year OB/GYN residents who are female has changed substantially in that time period. At the beginning of that period, OB/GYN residents were almost all male, whereas at the time of this writing more than 80% of first-year OB/GYN residents are female (Association of American Medical Colleges [AAMC], 2014; Rayburn, 2011). Thus, the OB/GYN profession has transitioned from a primarily male to a largely female profession.
Natural increases in the number of pregnancies in the United States and flat entries into the obstetric profession, coupled with this demographic shift, have important ramifications for workforce capacity. Female physicians balance their lives differently than their male colleagues, working fewer hours per week across nearly their entire careers, retiring from obstetric practice several years earlier, and working part time much more frequently (Rayburn, 2011). In addition, the profession is experiencing an increasing number of residents subspecializing in fields that do not involve maternity care (e.g., gynecological oncology, pelvic reconstructive surgery; Rayburn, Gilstrap, & Williams, 2012). As a result of these factors, the American College of Obstetricians and Gynecologists (ACOG) has estimated that by 2050, the United States will face a shortage of between 15,723 and 21,723 OB/GYNs (Rayburn, 2011).
266Educating more midwives is an excellent solution to this situation because their education is less expensive and more rapid than that of obstetricians. Midwives could attend a much larger percentage of uncomplicated births in the United States, taking significant pressure off the obstetric workforce. There is not a universally acknowledged estimate of the proportion of pregnant women who fall into low- or moderate-risk categories, the type of births that midwives most commonly attend. However, Centers for Disease Control and Prevention (CDC) assumptions and data can be used to estimate that 83% of first-time mothers are at low risk for a cesarean birth (Osterman & Martin, 2014) and the National Institutes of Health (NIH) has published statements about the prevalence of certain risk factors among pregnant women (National Institute of Child Health and Human Development, 2013). Furthermore, the United Nations Population Fund has estimated that properly trained midwives could provide 87% of maternity care needs (United Nations Population Fund, 2014).
It is a reasonable assumption that most women in the United States are likely to experience an uncomplicated birth and thus are good candidates for midwifery care. Because of this reality, many countries have structured their maternity care workforce so that the number of midwives exceeds that of obstetricians. A review of data on 20 high-resource countries shows that the median midwife-to-obstetrician ratio was 2.5 to 1. In the United States, for various reasons, this ratio is inverted; there are 0.28 midwives per obstetrician (American Midwifery Certification Board [AMCB], 2014; AAMC, 2014; Eguchi, 2009; Emons & Luiten, 2001; Rowland, McLeod, & Froese-Burns, 2012).
The assertion that midwives could attend a larger proportion of U.S. births is supported by actual data as well. For example, in several developed countries midwives attend between 70% and 80% of all births (Emons, 2001). In the United States, CNMs/CMs attended 8.33% of all births in 2014; however, in several states CNMs/CMs attended between 20% and 25% of births (CDC, 2014). Data on hospitals in New York and Massachusetts show that midwives attend between 30% and 70% of births in many facilities in those states (Bebinger, 2016; New York State Department of Health, 2014).
Parallel Growth of Midwives and Birth Centers
The case for a parallel scaling up of midwives and birth centers can be made. Improving the care experience and health outcomes for a population while at the same time reducing the costs fulfills the Triple Aim promoted by the Institute for Healthcare Improvement (IHI, n.d.; Berwick, 267Nolan, & Whittington, 2008). In order to meet these needs, a plan for educating more midwives must be put into place. Increasing the number of midwives educated along with the number of freestanding birth centers in the United States would help solve both workforce issues and lower the cost of care with a demonstrated quality care clinician and care model.
If policy makers take steps to promote midwifery education, mainly by supporting efforts to support clinical preceptors, the midwifery workforce in the United States could be rapidly grown to address the slowly evolving, but critical shortage of maternity care providers in our country. In addition, policy changes removing barriers to birth center growth would allow this underused care model to increase and provide access for women who would choose this physiologic approach to labor and birth in the United States.
TASK SHIFTING TO PROMOTE PHYSIOLOGIC BIRTH
In 2012, ACNM, Midwives Alliance of North America (MANA), and the National Association of Certified Professional Midwives (NACPM) released a consensus statement supporting physiologic birth (ACNM, MANA, & NACPM, 2012). In 2015, the promotion of physiologic birth was identified as a national priority by the National Partnership for Women and Families (2015). Birth centers are a care setting where physiologic birth is actively promoted, in contrast to hospital settings, which typically have high rates of medical intervention. This signature strength of birth centers has been described for more than 25 years (Rooks et al., 1989). Yet, less than 1% of births in the United States occur in freestanding birth centers (U.S. Department of Health and Human Services, Centers for Disease Control and Prevention [CDC], and National Center for Health Statistics, 2014). Preparing the workforce to manage more births in birth centers, thus offering greater opportunity for physiologic birth, requires a thoughtful analysis of the concept of task shifting.
The Origins of the Task-Shifting Concept
Task shifting is a global strategy addressing the workforce shortage. It involves critical analysis of necessary tasks and delineating these tasks, within a community framework, to the most available health care workers. It often entails a shifting of skills and skill upgrading to less skilled workers in order to maximize health care coverage for populations at risk (Fullerton & Anderson, 2017). This concept was first proposed by the 268Joint United Nations Programme on HIV/AIDS (UNAIDS), a division within the WHO, in response to the critical shortage of health care workers available to manage community-based HIV/AIDS programming (Piot, 2012; WHO, 2008a). The concept was rapidly adopted in international development planning and has been adapted to community-based care in both high- and low-resource nations (WHO, 2008b). By 2012, task shifting was endorsed by WHO as a strategy to disseminate essential care for mothers and newborns (WHO, 2015b). In a recent publication, O’Malley Floyd and Brunk (2016) examined this concept in the provision of rural, community-based midwifery care in Haiti, using exemplars from the organization Midwives for Haiti.
Task Shifting as a Strategy for Birth Center Care
Task shifting as a strategy to address limited human resources in maternity care can be extrapolated to improving access to safe birthing venues. Shifting the task of safe, affordable, and available care during childbearing to community-based birth centers is supported by the Affordable Care Act (ACA), evidenced by mandating Medicaid payment for services in state-licensed birth centers (Patient Protection and Affordable Care Act, 2009). Cost analysis and microcosting of task-shifting birth to community-based birth centers is currently being explored (Cole, Osborne, & Xu, 2015).
PREPARING THE MIDWIFERY WORKFORCE
For the birth center model to grow and function as anticipated, an adequate and well-trained workforce is required. In the United States, birth centers are primarily staffed by midwives with a range of educational backgrounds and preparation. This educational landscape for midwifery preparation is in variance to most other nations. In some nations, all nurses are trained in midwifery skills as part of basic nursing education. In other nations, midwifery is a specialty following nursing education or midwifery is a separate profession, unrelated to prior preparation as a nurse.
Pathways to Midwifery Education
In the United States, there are multiple pathways to becoming a midwife, some of which are not regulated or licensed.
The predominant pattern is entry into midwifery education following completion of the bachelor’s degree in nursing (BSN). Preparation for becoming a CNM is at the master’s level in nursing or may lead directly to the doctor of nursing practice (DNP) degree. It culminates with eligibility to sit for the midwifery certification exam conducted by the AMCB. Nurses holding a master’s or higher degree may complete a midwifery certification program without repeating the graduate-level courses in nursing (AMCB, 2015).
Another pathway is the accelerated master’s or doctoral program for persons coming from a non-nursing background. Graduate programs such as these, in schools of nursing, prepare persons with other educational backgrounds (minimally baccalaureate level and often higher level degrees) for the nursing profession and for the advanced practice profession of nurse-midwifery. This preparation results in eligibility to sit for the national registered nurse licensure examination and then the AMCB midwifery certification exam. Additionally, those nurses who hold an associate degree can enter what is termed a “bridge” program, directly entering a master’s program without earning a bachelor’s degree, with the same eligibility to sit for state licensure and national certification exams. Some CNMs are choosing to pursue doctoral education in either a research or practice capacity. A growing workforce requires a growing pool of educators, and education at the doctoral level may be required by educational institutions to teach rising professionals in the midwifery field. CNMs have the legal authority to practice in all 50 states and U.S. territories (AMCB, 2015).
Preparation for the CM credential does not require preparation as a registered nurse. The candidate for this certification must already hold a graduate degree or earn one in the process of midwifery preparation, meet the same standards applicable to nurse-midwifery education, graduate from an ACME-accredited program, and take the same AMCB-administered midwifery certification exam.
Two programs in the United States currently offer preparation as a CM. CMs can legally practice in five states with a sixth anticipated soon. In contrast, 40 programs offer nurse-midwifery education. All graduates of CNM and CM preparation programs meet the standards of the WHO-sponsored International Confederation of Midwives (ICM), which requires a 3-year midwifery education program, or an 18-month program if nursing is prerequisite, with both didactic and clinical education (ICM, 2013). 270According to AMCB, the number of CNMs and CMs continues to rise (AMCB, 2014).
There are no degree requirements for the direct-entry midwife (DEM) with self-study and apprenticeship as the predominant learning modes. DEMs may be eligible to take the North American Registry of Midwives (NARM) examination, resulting in certification as a certified professional midwife (CPM). Eligibility is established by documenting self-study and apprenticeship or by completion of a direct-entry midwifery educational program accredited by the Midwifery Education Accreditation Council (MEAC; Cheyney et al., 2015; NARM, 2016). Some states require DEMs to be licensed and 28 states authorize practice (MANA, 2015). Oregon has provided leadership in the licensure of DEMs (Oregon Health Licensing Agency, 2015). It is possible to practice as a licensed midwife (LM) if a state has that provision without also requiring certification as a CNM, CM, or CPM.
U.S. Midwifery Education, Regulation, and Association
The U.S. Midwifery Education, Regulation, and Association (USMERA) developed as a coalition of the various midwifery organizations in the United States seeking to build collaboration, promote physiologic birth, and create a common understanding of meeting ICM standards (USMERA, 2015). The landscape for entry into the midwifery profession in the United States is quite complex; most other nations have government-regulated midwifery education; however, consistency with ICM standards is quite variable (Bharj et al., 2016). Those practicing outside of this formal midwifery framework are identified as traditional birth attendants (TBAs) and usually do not have legal status.
The Birth Center Workforce
When considering the educational preparation of the birth center workforce, an examination of who comprises that workforce naturally follows. (For a more complete discussion of providers of birth center care, see Chapter 7.) In the United States, clinicians attending births in birth centers may include CNMs, CMs, CPMs, LMs, obstetricians, family practice physicians, or naturopathic physicians. In addition, other cadres of personnel function in support capacities in birth centers including nurse 271practitioners, registered nurses, and administrative and office managers. The most common birth attendant is the midwife. In 2013, government statistics indicated that the majority of births in birth centers were attended by CNMs and CMs. Of 16,913 births that occurred in birth centers in that year, 53% were attended by CNMs or CMs (Martin, Hamilton, Osterman, Curtin, & Mathews, 2015).
Most CNMs and CMs do not receive clinical experience in birth centers during their education. Their clinical experience occurs primarily in the hospital setting. Although their education meets ICM standards, they rarely have the opportunity to participate in community-based births, in a birth center or at home. Conversely, the education of CPMs and LMs, while not always consistent with ICM standards, provides experience in home and/or birth center settings. There is a need to increase the clinical experience of all categories of midwives in the United States in the birth center setting in order to reach the imperative of safe, affordable, and available community-based care. The experience is especially lacking in CNM and CM educational programs, creating barriers to adequate preparation of the workforce in birth center care and scaling up the availability of birth center care.
SCALING UP MIDWIFERY EDUCATION FOR BIRTH CENTER COMPETENCE
Barriers to Birth Center Education for Midwives
The United States lacks a national system of planning for health care professional education. The projections of retirement, attrition, and entrance into the health professions have been haphazard compared with more centrally planned economies. The popular press regularly publishes dire predictions, especially related to the impending nursing shortage. The fact that midwifery education in the United States is closely tied to the nursing pipeline can exacerbate the low availability of midwives. An idea to recruit more nurses to midwifery is to introduce midwifery in a more prominent way in undergraduate nursing programs with more content related to midwifery. This might ignite an earlier passion for the nursing route to midwifery. Furthermore, unlike most developed nations, the United States does not have a seamless system of referral from community-based systems of birth to high-acuity settings in an emergency transfer. The highly litigious environment surrounding health care and the lack of a well-coordinated referral system from community to hospital-based care 272in many communities can create an environment of fear around educating student midwives in birth centers.
In some midwifery education programs, the birth center model is promoted as a community-based model. Although there are more birth centers than ever before and the number increases every year, there are simply not enough birth centers to meet the demand for clinical placements. With 375 birth centers known to exist in the United States (S. Stapleton, personal communication, March 31, 2016) and with only approximately one fourth of those having attained accreditation, often a requirement for student program placement, it is easy to see the deficit this presents. Many more accredited birth centers are needed in order to create these clinical experiences for midwifery students.
Establishing the Conversation About Birth Center Education
A critical need in midwifery education is a broad-based conversation about ways to scale up the birth center experience. This conversation needs to include stakeholders from multiple backgrounds, not just educators. Creating a community-based learning environment includes public health workers, community citizens, hospital administrators, health professional cadres operating in hospitals, emergency room personnel, and first responders, among others. “Effective collaborations between midwifery education providers and clinical partners to adequately prepare students for their future midwifery practice should be promoted” (Bharj et al., 2016, p. 3).
Creating Communities of Practice
Setting up “communities of practice” as described by Bharj et al. (2016) is an essential first step. Educational institutions should offer faculty status to community-based birth center practitioners in order to empower their role as educators. Practitioners need to open clinical placements for students as future birth center practitioners and owners. One way to bridge this practice–education chasm is for educational programs to invest in university-linked birth centers. Such a facility not only provides a service for the community and a learning environment for midwifery students, but is also an excellent site for faculty practice. Modeling through faculty practice with a student at one’s elbow is a powerful learning strategy for deep learning during midwifery education.
A key element in fostering collaborative communities of practice is providing interprofessional education (IPE). WHO and the Institute of 273Medicine (IOM) have both promoted this approach to health professional learning (IOM, 2003; WHO, 2010). The IOM document, Health Professions Education: A Bridge to Quality (2003), is regarded as a mandate for improving quality of care. A central premise in both WHO and IOM documents is creating a culture of respectful teamwork (IOM, 2003; WHO, 2010). The Interprofessional Education Collaborative (IPEC), a coalition of health professionals from multiple disciplines, convened an expert panel to frame the competencies for IPE, first published in 2011 and updated in 2016 (IPEC, 2016). The basic assumption is that health professional students learning together in a community of collaboration will develop essential competencies and skills for bridging levels of care that they can use or build on following their education programs.
Designing Curricular Approaches to Promote Birth Centers
The AABC regularly conducts a workshop, “How to Start a Birth Center,” which addresses the business of midwifery and how to create a community-based practice (AABC, 2015). The workshop is currently offered five times per year in locations around the United States. It is attended by nurses, midwives, physicians, hospital administrators, and others considering starting a birth center, as well as midwifery students required by their educational program to take the course. The workshops fill up quickly, and require a substantial expense, which is often challenging for students who must typically travel to the workshop location. Ideally, this workshop would be included in midwifery education programs as an integral part of the curriculum. A possible opportunity to increase the number of programs offering this preparation would be to offer the workshop as an online course with self-paced modules, making it available to more students.
Another curricular approach is to use high-fidelity simulation techniques in portraying and critically reviewing birth center scenarios. This approach is powerful in exemplifying physiologic birth, teamwork, and the judgment and management required for referral to higher acuity care and hospital settings. These simulations can occur on a continuum of least to most complex and from early labor to postpartum and newborn care. Examples of simulations based on care delivered at a birth center are included in Table 12.1. The clinical scenarios displayed can occur in any setting, but the processes of assessment and clinical decision making are unique in the birth center setting, given the limited resources and possible need for transfer to a hospital. Of note is that even though the predominant practitioner in birth centers is the midwife, nursing students can learn by being involved with many of these simulations, as well as medical students and residents. Although most physicians will not practice in a birth center, they would benefit by learning more about physiologic birth as well as how complications and transfers are handled in the birth center setting. Ultimately, with IPE will come an increased understanding of the birth center environment and respect for each other’s profession and scope of practice.