HJNO Jan/Feb 2025

HEALTHCARE JOURNAL OF NEW ORLEANS I  JAN / FEB 2025 35 In the Sep/Oct 2024 issue of the Health- care Journal of New Orleans , the critical state of perinatal health in Louisiana was reviewed. The goal for this installment is to examine solutions. To recap, the Ameri- can College of Obstetricians and Gyne- cologists (ACOG) has predicted a looming shortage of up to 22,000 obstetrician-gy- necologists (OB-GYNs) by 2025. 1 A num- ber of factors has contributed to this defi- cit including: the practice climate in many states becoming increasingly difficult after the overturn of Roe v. Wade; aging of the workforce as many OB-GYNs near retire- ment age; and the burnout that physicians, and all healthcare providers in general, experience, which was only exacerbated by the COVID pandemic. Whereas physi- cians in the past often worked well into their 70s, more physicians are choosing to retire in their mid-60s. Another impor- tant factor impacting the shortage is the ever-rising malpractice insurance costs incurred by OB-GYNs and the constant stress of working in a medical specialty that is continually amongst the top 5 with the highest number of malpractice actions. This shortage has and will continue to particularly and radically affect those who are underserved as well as those who live in rural areas and maternity care deserts. Maternity care deserts are defined as counties with either limited or no access to hospitals providing mater- nity services, birth centers, or obstetric providers. More than half of the women who reside in rural counties live more than 30 minutes away from a hospital providing obstetrical services, which can literally mean the difference between life and death in an obstetric emergency. 2 Central to addressing the shortage issue has been a national discussion of better integration of midwifery services into the current obstetrical healthcare landscape. Midwifery, as defined by the American College of Nurse-Midwives (ACNM) — the U.S. professional organization rep- resenting certified nurse-midwives (CNMs) and certified midwives (CMs) — is: “Midwifery as practiced by certified nurse-midwives (CNMs) and certi- fied midwives (CMs) encompasses the independent provision of care during pregnancy, childbirth, and the postpar- tum period; sexual and reproductive health; gynecologic health; and family planning services, including preconcep- tion care. Midwives also provide pri- mary care for individuals from adoles- cence throughout the lifespan as well as care for the healthy newborn during the first 28 days of life. Midwifery care includes health promotion, disease prevention, risk assessment and man- agement, and individualized wellness education and counseling. These ser- vices are provided in partnership with individuals and families in diverse set- tings such as ambulatory care clinics, private offices, telehealth and other methods of remote care delivery, com- munity and public health systems, homes, hospitals, and birth centers. “CNMs and CMs are educated in graduate-level midwifery pro- grams and must pass a national certification exam to practice.” 3 Three types of midwives are recognized in the U.S.: CNMs, CMs, and certified pro- fessional midwives (CPMs). CNMs are edu- cated in the two disciplines of nursing and midwifery and have earned a minimum of a master’s degree obtained from a univer- sity-affiliated nurse-midwifery education- al program. CNMs are licensed in all states and practice in hospitals, out-of-hospital birth centers, and in homes, providing an- tenatal, labor and birth, and postpartum care, as well as caring for neonates the first 28 days of life. CNMs also provide primary and well-woman care through the lifespan. CMs are midwives educated in the dis- cipline of midwifery who do not hold a nursing degree and must have a mini- mum of a master’s degree. CMs practice in the same settings as CNMs, with the same scope of service provision, though they are licensed to practice in a limited number of states, Louisiana not among them. CNMs and CMs must pass the same certifying exam, administered by the American Midwifery Certification Board (AMCB), to receive the credential. CPM is a credential unique to North America that recognizes a variety of paths. Certification as a professional midwife does not require a college de- gree; it is based on the passage of a skills evaluation and written exam adminis- tered through a different organization, the North American Registry of Midwives (NARM), than that which administers the exam for CNMs and CMs. CPMs practice only in out-of-hospital and home birth settings and provide antenatal, labor and birth, postpartum, and well-woman care. GLOBAL VIEWOF MIDWIFERY Inarguably, midwifery is the gold stan- dard among high-income countries that have better maternal/neonatal out- comes than the U.S. 4 The 2014 The Lan- cet series on midwifery by Renfrew, et al., included a review of 13 metasynthe- ses (229 studies), 461 Cochrane reviews, and seven systematic reviews (114 tri- als), which revealed 56 patient outcomes positively affected by midwifery care. 5,6 Those 56 patient outcomes included reduced maternal and newborn morbid- ity and mortality and fetal loss rates. Key findings included lower preterm birth rates among midwifery patients, fewer low birthweight babies, lower interven- tion rates in labor, improved psychosocial outcomes, longer birth spacing and higher contraceptive use, higher rates of breast- feeding initiation and duration, shorter hospital stays, and improved referrals. 5