Wednesday, August 22, 2012

When Ideals Fail: CNMs and Collaboration

"Collaboration" in the world of midwives takes many forms.  For some states, midwives are required by law to work under the supervision of an OB, even to the extent that an OB signs off on a midwife's license before they can practice.  In other states midwives function more autonomously, yet still with checks and balances.  In MI, out-of-hospital birth is much like the Wild West. 

National organizations like ACOG and ACNM have issued statements, jointly in fact, that support the notion of collaborative care...meaning that OBs and CNMs come together to offer cohesive, seamless care relative to their expertise and education. 

     “Health care is most effective when it occurs in a system that facilitates 
      communication across care settings and among providers,” according 
      to the joint statement. “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.”

Collaborative Practice Statement, ACNM, ACOG

It's a noble ideal, and one that maternity care givers should undoubtedly strive for.  The trend toward collaborative care models is growing nationwide.  But what about MI, and specifically, what about the greater Lansing area who has only one nurse midwife delivering babies at one hospital...notably the hospital that doesn't have an RNICU?

The answer is that people are working toward changing that, slowly but surely.  What's concerning is that the current climate in our area is the exact opposite of collaboration.  Instead, we have a "freestanding" birth center who poses as "collaborative", but has no written agreement that articulates the specifics of that relationship.  When mistakes are made or when midwives have waited too long to get help, families are rushed to the ER in hopes of saving lives.  By then, it's far too late.  The relationship between birth center and hospital are complex to say the least, but it's fair to say the relationship is not working in favor of safety.  We need better options, we need safer care, we NEED a collaborative care model that functions in a healthy way.  No more illusions. 

ACNM states,
     "CNMs and CMs practice in collaboration and consultation with other health care 
      professionals, providing primary, gynecological and maternity care to women in the 
      context of the larger health care system." 

ACNM's document about US Certification Standards

Currently in Michigan, a CNM working in the out-of-hospital birth sector can "collaborate" with an OB as she sees fit, with no guidelines or mandates for such collaboration.  ACNM, a nurse midwife's parent organization does stipulate that care should be limited to low risk births.  Do some nurse midwives risk out appropriately?  Sure.  Are there out of hospital nurse midwives who collaborate seamlessly?  Perhaps.  Do some nurse midwives take chances and attribute high risk situations to "variations of normal"?  Yes they do, it happened to my family, and it's costing lives.  

The problem I have is that we have CNMs painting themselves as, "collaborators within a larger health care system, but nothing that holds them accountable for doing so.  Falsely claiming that you "collaborate" with a local physician, but then failing to do so when it's most obviously needed, should be considered fraudulent...on the part of both the nurse midwife and the "collaborating" physician.  There are many CNMs functioning within a healthy collaborative care model in the hospital setting.  There are not so many functioning in an unregulated, free for all setting of out-of-hospital birth.  There is a distinct difference in what is referred to as "collaboration", and the safety implications are paramount. 

Out of hospital birth practices offer no protocols for risking out or determining when that "collaboration" becomes necessary.  ACNM supports out-of-hospital birth, when attended by a legal, educated midwife for a low-risk birth.  What happens when a nurse midwife fails to risk out, fails to refer her high risk client for OB consultation, fails to see the need for collaboration altogether?  That answer is yet to be revealed.  I hope it is one synonymous with accountability.

The point here is that we must be clear about how we are defining "collaboration", and consistent with how we handle those times that safe collaboration fails to happen.  The women of the greater Lansing area deserve better options, those concurrent with evidence-based, best practices.  We need a collaborative care model we can count on, one who has safety as the utmost priority.  


  1. My midwife was a CNM who was practicing without the state-required collaborative agreement (which was not disclosed information). Collaboration is crucial. A CNM practicing without accountability to others is a nightmare that costs lives.

  2. My most unnerving experience with out of hospital birth here in Indiana was with a maverick cnm...and accountability in some real, practical form could have undoubtedly saved some lives