Transcription:

Prakash Chandran (Host): It's becoming more common for OB-GYNs to work with CNMs or certified nurse midwives. But little is understood about the working relationship between the two and what impacts CNMs can have on the patient experience. Today, we're going to discuss the details of this pairing from an OB-GYN perspective. Let's talk with Dr. Stephen Bashuk, Medical Director of Operations at OB Hospitalist Group.

This is The Obstetrics Podcast from OB Hospitalist Group. My name is Prakash Chandran. So Dr. Bashuk, thank you so much for being here. We really appreciate your time. I wanted to get started by asking as an OB-GYN, did you ever have any initial reservations about working with certified nurse midwives or CNMs?

Dr. Stephen Bashuk: I was in a unique position. I I did my residency at one of the great county hospitals in the country, Grady Hospital down in Atlanta, Georgia. And we had certified nurse midwives working with us from day one of my residency. So I spent four years with some of the most incredible midwives you could ever imagine. And I would say 50% to 75% of labor management, I learned from the midwives. Then when I graduated from residency and have landed my first job outside of residency was in a private group, and we had an old school midwife that had been doing it for 40 years. And again, just an amazing clinician and a great experience. So I started from the beginning working with wonderful people.

Prakash Chandran (Host): Yeah. You know, it really seems like you have this foundational respect for these midwives because, you know, you basically were trained with them and like you said, 50% to 70% of your knowledge comes from them. But that's not always the case. So I'm curious around like what kind of changes have you seen in the industry, the more broader industry, regarding CNMs in the recent years?

Dr. Stephen Bashuk: So I'm in the state of Arkansas and there are 70 counties in the state of Arkansas. Thirty-five of them are orphan counties, without any obstetric provider. So we have a huge access problem in this state. And the biggest change that I'm seeing is when we're addressing morbidity and mortality across this country, we have to look at our partners across the ocean in Europe. Eighty-five percent of their babies are born by midwives, and their morbidity and mortality is better than the United States. So we have to get to a place where the OB community understands that when a nurse midwife practices within their scope of care, they're very powerful and very safe. And a lot of providers are very nervous about working with certified nurse midwives.

And the number one reason why I think that occurs, and I may be going a little off subject, is there's a difference between a certified nurse midwife and a lay midwife. A certified nurse midwife goes through a rigorous training program, and they've got very unique training. A lay midwife does not have those requirements. And so all of us as OB-GYNs have gotten lay midwife patients that were, for lack of a better word, mismanaged, and that makes us nervous to work with midwives. But again, a certified nurse midwife is a very different person than an untrained person.

Prakash Chandran (Host): Yeah, thank you so much for that clarification. And you were kind of speaking to this already, but I imagine that the use of certified nurse midwives has increased quite a bit, just given the shortage of OB-GYNs. Is that the case?

Dr. Stephen Bashuk: Yes, absolutely. And again, in the state and I'll speak to my state, up until six months ago, midwives had to practice under the license of an OB-GYN. We just passed a law and I actually was part of the presentation of this law that gave independent scope of practice to midwives in the state of Arkansas, which put us on par with 27 of the other states in America. What that has allowed is now we can attract midwives to our state to fulfill these 35 orphaned counties and really where OB-GYNs are stretched very, very thin, we have the support of midwives to see the patients, give them excellent prenatal care and again, are very, very in tune to what their scope of practice is. And when they practice within that scope, very safe.

Prakash Chandran (Host): So, you know, you are both an OB-GYN and a medical director of operations for OB Hospitalist Group. In both of these roles, have you ever worked with certified nurse midwives that are actually part of the hospital-based care team?

Dr. Stephen Bashuk: I personally have not worked with a midwife on one of my care teams that I work at. We do have programs in OBHG, where the workload is beyond the capability of providing safe obstetrics care for one provider. There are multiple ways to address that and, in some of our programs, we hire a midwife to aid the main hospital as then, again, they are doing things like normal vaginal deliveries. They are seeing patients in the OB emergency department, and they act as a member of the team.

The key to working with a midwife and many OB-GYNs think of the midwife as being subservient to the physician, more of a parent relationship. And one of the biggest changes over the years that has come about is that model is not the best model for a lot of reasons. And we at OBHG support a collaborative model where we work together with the midwives. So when they are on the unit with us, they are a member of the team exactly like the physician.

Prakash Chandran (Host): Yeah. So let's unpack that a little bit. How does the presence of a certified nurse midwife on the team impact the patient experience and what impact do they also have on patient safety?

Dr. Stephen Bashuk: Well, number one, midwives generally aren't pulled in as many directions as a provider. So at my hospital, the midwives that deliver babies, they probably spend 10 to 12 more time actually in the room than the physician does. And the power of labor and delivery, it has to work as a team and every team member is important. And the midwife acts as a member of the team. They are skilled. They're able to see things that are not going exactly as we would want them to. And they work with their physician in those cases.

Again, the key is they're no different than any other member of the team be it a nurse, the person who cleans the room, the techs, and everybody, in the sense of the more you touch a patient, the more you are around the patient, the safer the environment is for that patient.

Prakash Chandran (Host): You know, I also feel like there's a certain level of comfort that they bring. You know, my wife and I, for my daughter's delivery, we use the certified nurse midwife and she just helped us stay present, understand what was going on, especially for me watching my wife for the first time go through those contractions and that pain. She gave us this level of ease and so we weren't overreacting to things. And I imagine that because of that reason, we're not overreacting to the other health providers in the room, which can ultimately lead to better outcomes. Do you find that to be the case?

Dr. Stephen Bashuk: Oh, I think that is absolutely the case. And, You know, that that is one of the most important functions that a midwife does, even in the prenatal process, if midwives generally will spend more time with the patient and getting to know what their wants and needs are, and also educating them about what the process is.

And it's exactly what you said. I mean, they're in the room. They're saying, "Okay, we're going to do X, Y, and Z. This is what we anticipate. If this doesn't happen, then we may do something different. And what's really important about this is that collaboration. So let's say a woman has high blood pressure in pregnancy. The midwife consults with the physician on how to handle preeclampsia. The physician will manage the preeclampsia and make sure that the blood pressure is controlled, all the measures and labs are within normal limits and make sure that patient is safe. And when you can do that with a midwife, the midwife has the relationship in a lot of ways. And so when she supports what the physician is doing and you're collaborating and you're working as a team, it makes the patient feel very comfortable with what's going on, even if it's not entirely in sync with what their birth plan is. And I think midwives support the communication with the patient as the labor progresses. So I agree a hundred percent with what you said.

Prakash Chandran (Host): So let's talk about community-based CNMs. You know, I understand that you testified in favor of a bill in Arkansas that would give midwives the ability to have an independent practice and perspective authority. What was the outcome and why is this so important to you?

Dr. Stephen Bashuk: When I joined OBHG, the hospitalist group, and I became a hospitalist, I got a very unique perspective of labor and delivery that I did not have as a private physician for 25 years. In private practice, I didn't work elbow to elbow with nurses, midwives, and frankly, everyone at the hospital for 24 hours. I was in my office. I was seeing patients. I would be called if there was an issue with the patient or if it was just time for delivering.

And one of the things I've discovered over the years is we do have a morbidity and mortality crisis in this country, especially with African-Americans. They are four times more likely to have morbidity and mortality than their white counterparts. And that number is actually corrected for many factors and it really comes down to unconscious bias in our system. And when I really started realizing what the role of a hospitalist could be in the big picture and how labor and delivery when it functions as a team is such a safe environment and so much more safe than I ever could imagine. And as a hospitalist, I felt I made such a big difference in so many people's lives.

The reason I testified is I've worked with a lot of great midwives. And as I said, my career started with midwives and, throughout my private career off and on, I worked with midwives in a lot of different scenarios, and these are very skilled providers. And I just feel very strongly that a woman in a small town in Arkansas doesn't have the means to travel an hour and a half to Little Rock to get her prenatal care. So that woman is more likely just to show up at the hospital without prenatal care. And, you know, so it starts from the moment they get that positive pregnancy test and enroll in prenatal care and get educated and really become part of having a child. And we just are not graduating enough OBs to provide care for all the women in this country. And again, I think midwives are extremely talented. And when they identify, you know, a woman who's 28 weeks with high blood pressure, and she transfers that patient to an OB-GYN, that makes a huge difference in that woman's life.

And I tell the people who work for me every day, I mean, we see these and when they show up at the hospital, it doesn't matter if you're the CEO of Coca-Cola or the poorest person from Pine Bluff, Arkansas, you're scared, you're nervous. You don't know what's going on. And as a hospitalist, the ability to take care of that patient, provide them care is paramount.

I testified, because exactly what I said to you about Europe, I think we have to fix the access problem in this country. And I think midwives are a big part of that solution. And I want every woman to get care for their baby.

Prakash Chandran (Host): So Dr. Bashuk, those are really powerful statements. And I think you've covered really well why the relationship between the OB-GYN and the CNM is so important. As we start to close, what tips might you have for OB-GYNs and CNMs about working together?

Dr. Stephen Bashuk: The number one tip I would give you is you have to leave the mindset that they're a mid-level working for you, that they are a skilled professional that is working with you. It is the collaboration with midwives that will make a huge difference in the morbidity and mortality of this country. And that is the tip. I mean, it is a collaboration.

Prakash Chandran (Host): Well, Dr. Bashuk, I think that is the perfect place to end. Thank you so much for your time today.

That was Dr. Steven Bashuk, Medical Director of Operations at OB Hospitalist Group. Thanks for checking out this episode of the OB Hospitalist Group Podcast series. To learn more, you can visit obhg.com. If you found this podcast to be helpful, please share it on your social channels and be sure to check out the entire podcast library for topics of interest to you.

My name is Prakash Chandran. Thanks again for listening, and we'll talk next time.