Relevant Background:

On 2/27/23, IU Health Arnett (IUHA) communicated to their Certified Nurse Midwives (CNM) on staff that they would no longer have labor and delivery privileges. This change came after years of gradual diminution of both their patient care privileges and perceived respect from their surgeon colleagues. Despite favorable birth outcomes, high patient satisfaction, evidence-based guidelines, and the continually demonstrated skill, knowledge, and passion from the midwife team since 2009, IUHA began rescinding patient cases and care options from the midwives as early as January of 2020. These changes include added restrictions inconsistent with statements from the American College of Nurse-Midwives (ACNM) in care for patients with: controlled gestational diabetes and those seeking a Vaginal Birth After a Cesarean (VBAC).

In the fall of 2022, midwife covered call shifts were cut to only 60-70% coverage time. Initially, this change was not communicated to patients expecting midwifery care at delivery.

Prior to the complete revocation of midwife deliveries, the program was said to be “indefinitely paused”. This change was not communicated to patients or relevant IUHA staff members, leading to confusion for all involved. In some cases, patients were not informed of the change until arriving to the facility in active labor.

When IUHA chose to completely prohibit the inpatient midwifery program (i.e. allowing their staff CNMs to attend births) they still did not initially communicate the change to their patients. Additionally, reasons communicated were rife, inconsistent, and in some cases: outright falsehoods.

We believe that IUHA administration’s lack of support for building the midwife team in morale and numbers, as well as their inexcusable communication, is directly causing a reduction in patient care quality and options. The American College of Obstetricians and Gynecologists(ACOG) and ACNM’s Taskforce on Collaborative Practice supports this in the following quotation: “Practices should encourage patients to be a part of the decision making process regarding team role and responsibility changes and, if patients are not part of this process, they should receive complete, timely information regarding these changes.”[1]

Overall, the actions of IUHA are inconsistent with ACOG policies and statements regarding midwifery and team collaboration. Most notably, in the ACOG’s policy priority page entitled “Midwifery” is the following statement: “ACOG respects a pregnant person’s right to make a medically informed decision about their birth attendant and place of delivery and believes hospitals and licensed, accredited birth centers are the safest setting for birth. ACOG supports the standards used by the American Midwifery Certification Board (AMCB) which credentials certified nurse-midwives (CNM) and certified midwives (CM). ACOG’s Joint Statement of Policy with the American College of Nurse-Midwives supports CNMs and CMs practicing to the full extent of their credential, training, and experience.”[2]

 Current State

Prior to the sudden elimination of midwife call shifts at IUHA on 2/27/23, the only option for hospital-based midwifery care and deliveries in the greater Lafayette area was with the team at IUHA. Currently, both Franciscan Health and IUHA have CNM on staff who are only permitted to care for patients in the outpatient office setting. As of original petition date, CNMs are not authorized to support their patients in labor, thus annulling much of the objectives in their model of care. CNMs are currently not authorized to deliver the babies of the patients that they had spent months building trust, relationships, and strategies with.

Midwives are a safe option for all stages of prenatal and birthing care. A 2019 article in Scientific American asserts “Studies show that midwife-attended births are as safe as physician-attended ones, and they are associated with lower rates of C-sections and other interventions that can be costly, risky and disruptive to the labor process.”[3] They go on to say that “But midwifery still remains on the margins of maternity care in the U.S.”3. Unfortunately, in Lafayette, midwives are no longer even on the margins, they have been forced out of the birthing rooms entirely.

Petition Entreaties:

We are urging the hospital systems in the Lafayette area, both IU Health Arnett and  Franciscan Health (formerly known as St. Elizabeth), to initiate or reinforce their hospital-based midwife programs with the following specifications:

A.     At IUHA: Fully reinstate the delivery privileges of the midwife team that were in place as of January 2023, to reflect the needs and desires of the Greater Lafayette community, as recommended by the ACOG taskforce in the following quote: “The composition of a care team will then depend on the local population and population health.”1

B.      At IUHA: Reevaluate the policies regarding the care of patients with controlled gestational diabetes by a committee comprised of equal representation from ACNM and ACOG. Specifically, patients with controlled gestational diabetes (either with diet or medication) be permitted to deliver at the hospital with an IUHA midwife.

C.      At IUHA: Reevaluate the policies regarding the care of patients seeking VBAC by a committee comprised of equal representation from ACNM and ACOG. Specifically, that VBAC cases do not require OB/GYN approval, in accordance with ACNM’s declaration,“Certified nurse-midwives and certified midwives are qualified to provide antepartum and intrapartum care for women who are candidates for VBAC.”[4]

D.     At IUHA: Allow the midwife team to consider and determine patient risk for a VBAC patient’s ability to safely deliver in the birthing tub with a highly skilled midwife provider, reflective of the discernment and provision of ACNM’s statements on Hydrotherapy During Labor and Birth[5] and VBAC[3].

E.      At both facilities: Assure the equal partnerships between Midwives and OB/GYNs as members on a collaborative team, without a hierarchy evocative of employee and supervisor. ACOG’s taskforce defines such a team in the following quote from their executive summary: “Collaboration is a process involving mutually beneficial active participants between autonomous individuals whose relationships are governed by negotiated shared norms and vision. Collaboration is necessary for a team to function optimally.” At Franciscan Health, specifically: adapt the current outpatient only midwife options to include a fully staffed midwife inpatient delivery program.

F.      At both facilities: Ensure a midwife representative on every board that oversees topics including, but not limited to, budget, staffing, licensure, patient care, and policy creation, with the following advice from ACOG’s taskforce in mind: “Health care providers and practices seeking to build interprofessional health care teams should understand the scope of practice and licensure of each member of the health care team.”[1]

G.     At both facilities: Allow patients to practice comfort measures to limit intervention during birth, as outlined in ACOG’s February 2019 committee opinion[6], including but not limited to intermittent monitoring, use of a doula, oral hydration and nourishment, freedom of movement and position in labor, freedom of movement and position in pushing. Further, that intimidating and hypothetical language not be used to influence a patient’s decision when there is no indication of potential harm. (E.g. “you don’t ‘x’ situation if ‘y’ were to happen”). Further, that intermittent monitoring be defined facility wide among a committee of practitioners with midwife, surgical, nursing, administrative and other relevant staff members; once decided, have a written copy of those policies available for patients and staff to ensure consistency in communication.

H.     At both facilities: Allow patients who have not received pharmacological pain management to labor  in tub, under the care of any provider as described in ACOG’s committee opinion on Immersion in Water During Labor and Delivery[7]. Allow each team (i.e. midwives and surgeons) to determine their candidate selection criteria for delivery in the tub and have a written copy of those policies available for patients and staff to ensure consistency in communication.

I.       At both facilities: Restructure and eliminate any existing volume-based payment systems to wholly ensure any financial conflicts of interests. This provision is also identified in ACOG’s collaborative taskforce statement: “Payment systems should evolve so that all members of the team can benefit from financial incentives based on outcomes and value of care instead of exclusively by procedure or volume of procedures…” On their website, ACOG has a public webinar available for information on shifting to value-based pay.[8] They acknowledge that a shift to focus on quality of care will improve patient outcomes and that there is bipartisan support for reforming existing health payment systems.

J.       At both facilities: Publish an annual report of birth outcomes (including, but not limited to
the rates of: induction of labor, cesarean birth, epidural usage, successful VBACs, post-partum hemorrhage and 3rd or 4th degree lacerations) with local media outlets (e.g. WLFI, the Journal & Courier, and Star City News), per provider, for transparency in patient decision making and as data for public health discourse. Patients will be better equipped to align their goals with that of their provider with clear and concise releases of information. Further, an annual publication will illustrate a respect towards patients’ autonomy, as mentioned in the taskforce statement, “Care always should be patient centered in that it is focused on the health needs of the patient; respects the patient’s values, preferences, and goals; is based on an enduring personal relationship; and sees the patient as a partner in managing his or her health and making health care decisions. This patient centeredness should be as valued as clinical outcomes.”

K.      At both facilities: Encourage and promote cross training among midwife and surgeon teams. Ensure that at least one midwife attend ACOG’s annual conference and at least one surgeon attend ACNM’s annual conference. Additionally, require the following trainings for all midwife and OBGYN providers: a training on physiological birth (such as that with Dr. Stuart Fischbein[9]), a triennial (or more frequent) group review of the ACOG/ACNM taskforce’s 7 Core Interprofessional Education modules[10] and a waterbirth training of all OBGYNs and midwives to guarantee safety and consistency in care. These stipulations align with ACOG’s taskforce’s assertion that “continuous professional development among all team members Is essential.”[1]

L.      At both facilities: Support legislative proposals that eliminate collaborating physician requirements for APRNs in the state of Indiana, such as Indiana SB213[11] and HB1330[12], which would allow Indiana to join 26 other US states that have followed the recommendation of the National Academy of Medicine as a method for alleviating the increasing numbers of physician shortages.[13]

Conclusion

We believe that midwife care is safe, cost-efficient, and necessary. We believe that all birthing persons deserve the right to have an option of midwife-based care in their community.  We believe that IUHA acted irresponsibly and unethically in their handling of the midwife program as well as the dissemination of information to the community, patients, and staffs. We believe that outpatient and office hours only accessibility of midwives is not truly a midwife program. We believe that any organization that insists it has a midwife program, yet does not allow midwives to serve their patients in delivery, is being dishonest in a manner that borders on a breach of consent and autonomy. We believe that the above conditions will help rectify  the damage that was done. We believe that the above conditions will allow the Greater Lafayette birthing community to be a first-rate example of evidence-based, safe, and collaborative care for birthing persons.

#LafayetteWheresMyMidwife

References 
[1] Executive summary: Collaboration in practice: implementing team-based care. American College of Obstetricians and Gynecologists. Obstet Gynecol 2016; 127:612-7.
[2] Midwifery. ACOG. https://www.acog.org/advocacy/policy-priorities/midwifery Published n.d.. Accessed March 16, 2023. 
[3] The Editors. The U.S. needs more midwives for Better Maternity Care. Scientific American. https://www.scientificamerican.com/article/the-u-s-needs-more-midwives-for-better-maternity-care/#:~:text=Studies%20show%20that%20midwife%2Dattended,disruptive%20to%20the%20labor%20process Published February 1, 2019. Accessed March 17, 2023.
[4] ACNM Board of Directors. Vaginal birth after cesarean - American College of Nurse Midwives. ACNM. https://www.midwife.org/acnm/files/ACNMLibraryData/UPLOADFILENAME/000000000090/VBAC-PS-FINAL-10-10-17.pdf Published September 2017. Accessed March 16, 2023. 
[5] ACNM Board of Directors. Hydrotherapy during labor and birth - American College of Nurse-Midwives. ACNM. https://www.midwife.org/acnm/files/ccLibraryFiles/Filename/000000004048/Hydrotherapy-During-Labor-and-Birth-April-2014.pdf Published April 2014. Accessed March 16, 2023. 
[6] ACOG. Approaches to limit intervention during labor and birth. ACOG Committee Opinion No. 766. American College  of Obstetricians and Gynecologists. Obstet Gynecol 2019; 133:e164:-73.
[7] ACOG. Immersion in water during labor and delivery. Committee Opinion No. 679. American College of Obstetricians and Gynecologists. Obstet Gynecol 2016; 128:e231-6.
[8] Link: https://www.acog.org/education-and-events/webinars/value-based-payment-concepts
[9] Link: http://www.birthinginstincts.com/events
[10] Link: https://acnm-acog-ipe.org/module/
[11] Link: https://iga.in.gov/legislative/2023/bills/senate/213
[12] https://iga.in.gov/legislative/2023/bills/house/1330
[13] National Academies of Sciences, Engineering, and Medicine; National Academy of Medicine; Committee on the Future of Nursing 2020–2030; Flaubert JL, Le Menestrel S, Williams DR, et al., editors. The Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity. Washington (DC): National Academies Press (US); 2021 May 11. Summary. Available from: https://www.ncbi.nlm.nih.gov/books/NBK573919/