virginia licensed midwives

Licensed Midwives in Virginia Workgroup on Midwifery and Medications February 4, 2011 :

Licensed Midwives in Virginia Workgroup on Midwifery and Medications February 4, 2011 Deren Bader, CPM, DrPH Brynne Potter, CPM

Presentation Outline :

Presentation Outline Midwifery and Medicine History and Culture Challenges with Collaboration Models for Consultation (MVM Case Review) 2010 Home Birth Data Medications CPM Scope of Practice Review of What is Happening Now Options for Change

Midwifery and Medicine: Cultural Divide:

Midwifery and Medicine: Cultural Divide

Midwifery and Medicine: Conflict not Conversation:

Midwifery and Medicine: Conflict not Conversation

Midwifery and Medicine: Women are Bypassing the Battle :

Midwifery and Medicine: Women are Bypassing the Battle

Midwives: Our Process Looks Different..:

Midwives: Our Process Looks Different..

but our goals are the same…:

but our goals are the same…

Good Outcomes!:

Good Outcomes!

Better Outcomes in Maternity Care:

Better Outcomes in Maternity Care Childbirth Connection Transforming Maternity Care Project: “Who needs to do what, to, for, and with whom to improve the quality of maternity care over the next five years?”

Blueprint for Action: Clinical Controversies: Home Birth, VBAC, Vaginal Breech and Twin Birth, Elective Induction, and Cesarean Section without Indication :

Blueprint for Action: Clinical Controversies: Home Birth, VBAC, Vaginal Breech and Twin Birth, Elective Induction, and Cesarean Section without Indication “Childbearing women with controversial clinical situations face mixed professional messages and disagreement about appropriate care and care options.” “Liability concerns impact the care of women with controversial clinical scenarios. Perceived pressure pushes some clinicians and systems of care to make decisions with the primary aim of avoiding liability rather than supporting a healthy physiologic childbirth and honoring women's informed choices.”

VA Healthcare Reform Directive:

VA Healthcare Reform Directive On “Capacity” (pg 47): “Scope of practice restrictions may limit the ability to fully expand capacity as much as optimal “team” care delivery might allow.” “Considerable clinical and practical evidence suggests that some scope of practice restrictions and supervisory plus care delivery norms in Virginia may no longer be necessary to protect the health and safety of the public and may indeed contribute to inefficient and even ineffective care delivery and thereby raise costs unnecessarily.

Mandated Collaboration/Supervision:

Mandated Collaboration/ Supervision Written protocol Development of guidelines that define consultation among the collaborating parties and the patient; Evaluation of services provided Physician on site or regular site visits Individualized determination of medications and protocols Provide patient with contact info of physician Physician may restrict access to specific medications Collaboration: Supervision:

Mandated Supervision/Collaboration:

Mandated Supervision/Collaboration Challenges for Home Birth: Responsibility/Liability for Supervising Providers

Mandated Supervision/Collaboration:

Mandated Supervision/Collaboration Challenges for Home Birth: Responsibility/Liability for Supervising Providers Different Standards of Care On site Supervision is Not Possible Consumers Reject Mandated Relationships w/Physicians Fear of harassment Consumers insisted on this section of the CPM statute: § 54.1-2957.9. …Such regulations shall not (a) require any agreement, written or otherwise, with another health care professional or (b) require the assessment of a woman who is seeking midwifery services by another health care professional.

Case Review: Mountain View Midwives:

Case Review: Mountain View Midwives Mountain View Midwives, PC has no formal/written agreement with any obstetrical or pediatric providers

A. Client -2010:

A. Client -2010 31 y/o, white, married, G1 P0 Had initial visit with PCP at 6 weeks Medical Hx: Macropapillary serous carcinoma of the right ovary Declined genetic screening Normal routine anatomical survey @ 22 weeks 50-gram glucose challenge was normal at 28 weeks Declined screening for GBS Risk Based Screening in labor Rh-neg Had 28 week Rhogam from PCP Baby Rh-neg

Points of Consultation:

Points of Consultation Detected fetal arrhythmia @ 32 weeks MFM-2 visits Ultrasound Fetal echocardiogram Assessment for post-dates MFM for BPP Delivered at home at 42 weeks 4 days Abnormal NBS results Facilitate the involvement of newborn PCP Ante Partum Post Partum

Virginia Licensure for CPMs:

Virginia Licensure for CPMs The first licenses were issued in January 2006. Currently there are 55 midwives with active licenses. Of these, 36 live in VA 24 attended births in 2010 28 plan to attend births in 2011. License Look-up page at the VA-BOM site: https://secure01.virginiainteractive.org/dhp/cgi-bin/search_publicdb.cgi

2010 Practice Composition:

2010 Practice Composition 10 solo practicing midwives 6 partnerships with 2-3 midwives 11-114 clients in 2010 All but 2 midwives report they will attend more births in 2011. For some of the more newly licensed midwives there will be a big increase for 2011.

2010 Midwife Practices:

2010 Midwife Practices

2010 Birth Data:

2010 Birth Data 573 women started care with CPM 4.4 % transferred care prior to labor (25/573) 549 started labor intending to birth at home 11.4% intra-partum transfer of care (63/549) 88.5% births occurred at home (486/549) 4.3% Maternal postpartum transfer (21/486) 1.4% Newborn post-partum transfer (7/486)

Transfer to Physician Care:

Transfer to Physician Care From the Literature 7-18% ante-partum referrals 8-12% intra-partum transfer 1-2% postpartum maternal transfer 1-2% neonatal transfer 2010 Virginia Midwives 4.4% ante-partum referrals 11.4% intra-partum transfers 4.3% postpartum maternal transfer 1.4% neonatal transfer

Medications in CPM Scope of Practice:

Medications in CPM Scope of Practice Anti-hemorrhagic medications: IM Pitocin Methergine Medical Oxygen-for maternal and newborn uses Rho(D ) immune globulin-for Rh negative mothers Vitamin K-for newborns Erythromycin-for newborns Antibiotics-for mother with +GBS culture IV fluids-for mother for dehydration or hypovolemia Lidocaine - for suturing

Collaboration Obstacles: Convenience:

Collaboration Obstacles: Convenience Compliance prior to licensure: Newborn Metabolic Screening: 0-25% Medical Ultrasounds: 0-10% Compliance after licensure: Newborn Metabolic Screening: 100% Medical Ultrasounds: 20-80%

Prenatal Rho(D) Immune Globulin: 0-20% Why don’t they get it? :

Prenatal Rho(D) Immune Globulin: 0-20% Why don’t they get it? No willing provider Fear of harassment In some areas using HD Miscommunication Inefficient Harassment & criticism In some areas have tried ED This option has not been successful Most women do without

Postpartum Rho(D) Immune Globulin: 0-90% :

Postpartum Rho(D ) Immune Globulin: 0-90% Strong desire among women to receive postnatal Rho(D) immune globulin. Timely Requires women to leave home and seek care elsewhere. This alone serves as a deterrent for some women. In many areas there does not seem to be a willing provider available to prescribe or administer. ED Long wait time in the ED with a newly delivered mother (and baby). Harassment HD Long wait time with a newly delivered mother (and baby). HD closed on weekends has caused a problem when delivery occurs on Friday. Criticism Go without despite a desire to have it.

Vitamin K: 0-10%:

Vitamin K: 0-10% Timely Should be administered immediately after birth Most midwives offer the option of an oral preparation. In NOVA having a problem with Physicians refusing to see baby if not had vitamin K Conundrum! Parents perceive this as harassment. Reports of refusing care because baby was born at home even when they are caring for older siblings.

Newborn Eye Prophylaxis 0%:

Newborn Eye Prophylaxis 0% Timely Should be administered shortly after birth. Required by law Many parents decline For parents who desire NEP they can try to get a prescription from a PCP prior to birth and administer it themselves. Difficult in some areas to find a willing provider.

IAP for GBS: 0%:

IAP for GBS: 0% CPMs can offer screening but not IAP Many decline screening. Use risk-based intra-partum screening 0% of GBS+ women chose to transfer care for hospital birth for IAP based on GBS status alone. CPM access to IAP could increase rate of screening Increase the acceptance of treatment in labor

Lidocaine:

Lidocaine Most midwives are using some form of over-the-counter lidocaine gel or spray and ice to numb the area to be repaired. This offers limited comfort for the mother during repair. Women do not want to transfer care for minor repairs but are reluctant to do the repair without proper anesthetic. Repair is a miserable experience No repair is done

Emergency Medications: Anti-hemorrhagic Medication:

Emergency Medications: Anti-hemorrhagic Medication Concern from the midwives It goes against what we are taught and trained to do. Frustration Delay in care Avoid transfer Less loss of blood Woman placed at increased risk with delay in administration Oxygen would have been beneficial

Emergency Medications: Oxygen:

Emergency Medications: Oxygen Maternal Non-reassuring FHT (8) Transfer by private vehicle PPH (15) Newborn TTN (5) Transfer by private vehicle RD (1)

Gap in Care :

Gap in Care Per letter from EMS sent to Board of Medicine, December 1, 2009: VAEMS does not have a mechanism to include anti-hemorrhagic medications on all ambulances. Majority of Advanced Life Support (ALS) EMS providers do not have training to support administration of anti-hemorrhagic medications. Majority of EMS providers in rural areas do not have ALS training EMS recommends that midwives provide care with support of EMS for support and transport only

Option 1: Prescriber Relationship:

Option 1: Prescriber Relationship CPM Statute Amendment : § 54.1-2957.9. Regulation of the practice of midwifery. The Board shall adopt regulations governing the practice of midwifery, upon consultation with the Advisory Board on Midwifery. The regulations shall ( i ) address the requirements for licensure to practice midwifery, including the establishment of standards of care, (ii) be consistent with the North American Registry of Midwives' current job description for the profession and the National Association of Certified Professional Midwives' standards of practice, except that prescriptive authority and the possession and administration of controlled substances shall be prohibited, Drug Control Act Amendment : §54.-3408 Pursuant to a written order of standing protocol issued by the prescriber within the course of his professional practice, such prescriber may authorize the administration of certain drugs by licensed midwives within their scope of practice or training and in accordance with regulations promulgated by the Board of Medicine.

Option 1: Prescriber Relationship:

Option 1: Prescriber Relationship Benefits: Establishes formal collaboration between midwives and medical providers. Allows for flexibility in the formulary as long as protocols for use are outlined by the prescriber. This increases access to care for conditions that the midwife is qualified to evaluate, but not treat. Not Precedent Setting Challenges: Requires participation by the medical community Challenge for midwives and consumers to find physicians willing to participate in collaboration of any kind. Possibility of utilizing VDH Regional Medical Directors as an umbrella for care? Fear of harassment of women planning home birth when they seek out the care of physicians for medical conditions during their pregnancy. Prescription filled for every client, when most drugs are rarely used increases cost and waste No system for tracking use of medications by midwives

Option 2: Controlled Substance Registration:

Option 2: Controlled Substance Registration CPM Statute Amendment : § 54.1-2957.9. Regulation of the practice of midwifery. The Board shall adopt regulations governing the practice of midwifery, upon consultation with the Advisory Board on Midwifery. The regulations shall ( i ) address the requirements for licensure to practice midwifery, including the establishment of standards of care, (ii) be consistent with the North American Registry of Midwives' current job description for the profession and the National Association of Certified Professional Midwives' standards of practice, except that prescriptive authority and the possession and administration of controlled substances shall be prohibited, Drug Control Act Amendment : §54.-3408 -authorize midwives to possess and administer specific drugs via protocol TBD.

Option 2: Controlled Substance Registration:

Option 2: Controlled Substance Registration Benefits: May be less cumbersome and more suitable to the scope of practice of CPMs. Protocols developed by the Board of Medicine could include additional training, reporting, and specific administration protocols. If the midwife was carrying these substances to be used “as needed”, then there would be no waste or burdensome costs associated. The Board of Pharmacy and Department of Health already administer this registration, so it would not be a new model. Challenges: CMA is unfamiliar with all the details of how this model will work. The application appears to require a supervising physician in some categories and not in others. A requirement for supervision creates practical and legal barriers because there cannot be direct supervision at the time of administration.

Option 3: Colorado model:

Option 3: Colorado model January 2011- Regulatory Review by Dept of Regulatory Agencies(DORA): Key DORA Recommendations: Allow direct-entry midwives to obtain and administer vitamin K and specific medications. The following vitamin and medications are life-saving, prophylactic treatments for women and babies: Vitamin K; Rho(D) immune globulin; and  anti-hemorrhagic drugs.* “Direct-entry midwives [CPMs] are trained and tested on the use of vitamin K, Rho(D) immune globulin, and anti-hemorrhagic drugs. Allowing direct-entry midwives to administer them is consistent with the public interest.” * In legislative hearing Jan 19, 2011, committee added IVs and Lidocaine based on consumer testimony

Option 3: Colorado “Limited Prescriptive Authority”:

Option 3: Colorado “Limited Prescriptive Authority” (From Colorado Report): “One solution would be to allow direct-entry midwives to administer [the vitamin K*] but require them to obtain the prescription from a physician (our Option 1). In Colorado, this solution is not workable. Unfortunately, liability issues make it difficult for physicians to consult with direct-entry midwives. While some direct-entry midwives may not have any problem obtaining vitamin K from physicians, many would find it impossible.” “Ideally, direct-entry midwives would be granted the authority to obtain [vitamin K*] directly from a pharmacy. The second sunset criterion asks whether the existing statutes and regulations establish the least restrictive form of regulation consistent with the public interest. Allowing direct-entry midwives to obtain and administer [vitamin K*] is the least restrictive form of regulation because it allows direct-entry midwives to perform the job that they are trained to do, and it is consistent with the public interest because it decreases the risk of serious complications.” *Same argument repeats for Rho(D) immune globulin and anti-hemorrhagic drugs

Option 3: Limited Prescriptive Authority:

Option 3: Limited Prescriptive Authority Challenges: “Lack of consensus in Virginia regarding expanding scope of practice for any providers”. -Virginia Health Care Reform Directive pg 47 Concern about “flood gate” from other providers. -Workgroup on Midwifery and Medications, Dec 3, 2010

Option 4: Do Nothing:

Option 4: Do Nothing Benefits: ?? Challenges: Contrary to public safety Contradictory to the motion from the last meeting

Summary of Options for Discussion:

Summary of Options for Discussion Option 1: Prescriber Model Option 2: Controlled Substance Registration Option 3: Limited Prescriptive Authority Option 4: Do Nothing