ACOG's Letter of Concern Regarding Collaborative Agreements

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By Jill—Unnecesarean

A CNM student shared these documents regarding ACOG’s resistance to the elimination of collaborative agreements between CNMs and OB/GYNs. Their concern turned to outright opposition last week when ACOG held a press conference in Albany to protest the Midwifery Modernization Act, calling the bill “an absolute disaster” that will result in “a step backwards in patient safety”.

  

April 9, 2010

 

Honorable Richard N. Gottfried

New York State Assembly

822 Legislative Office Building

Albany, New York 12248

 

RE: Letter of Concern – Elimination of Certified Nurse Midwife Collaborative Agreements (A.8117/S.5007)

 

Dear Assemblyman Gottfried,

On behalf of The American Congress of Obstetricians and Gynecologists, District II (ACOG), I would like to express my extreme dissatisfaction over your legislation to eliminate the written collaborative agreement between obstetrician-gynecologists and certified nurse midwives. From ACOG’s perspective, this legislation is ill advised, untimely, and unnecessary – and could potentially put patients at risk.

ACOG recognizes the unique relationship between ob-gyns and certified nurse midwives. Midwives play an integral role in the delivery of women’s health care and ACOG firmly believes that this relationship is enhanced by a statutorily required written collaborative practice agreement between ob-gyns and midwives that prevents ambiguity, especially in regard to high-risk births. Additionally, this written agreement has worked effectively and seamlessly since it was first established in 1992. Many ob-gyns and midwives rely on this written communication to carefully detail the responsibilities of each provider when caring for obstetric patients.

A written practice agreement guarantees optimal patient care in the case of the unfortunate occurrence of a high-risk situation where a midwife requires the assistance of an ob-gyn. Optimal patient care is afforded to patients when communication between midwives and ob-gyns occurs at the beginning of pregnancy. Strong communication weakens risk exposure and improves the chances of a liability claim.

Without a collaborative agreement, midwives face a higher risk exposure and thus, the possible failure to obtain medical liability insurance. This legislation would surely increase a midwife’s malpractice burden and increase the cost of his/her liability insurance. There is no question that each year, ob-gyns practicing in New York face the inevitability of escalating premiums which can easily reach nearly $200,000 in parts of the state. Some insurance companies do not even want to insure providers that they deem high-risk. In this scenario a midwife would virtually become uninsurable.

Over the past several years, we have seen the health care system incorporate new practices and procedures for increasing patient safety, particularly in the area of obstetrics. Team training and “train-the-trainer” initiatives are just some of the collaborative models hospitals across New York are implementing. This legislation has the potential to unravel this framework.

Furthermore, supporters of this legislation will tell you that ob-gyns across New York State are refusing to sign collaborative agreements and in some areas there is not a single ob-gyn to sign one at all. There is no data to support these claims and ACOG’s continued insistence for such data has been rebuffed. If such instances do, in fact, exist, ACOG would take every opportunity to educate and inform its ob-gyns of the importance of a written collaborative agreement.

If you wish to discuss this legislation further, please contact Donna Montalto, MPP, ACOG District II Executive Director, at 518-436-3461 or at dmontalto@ny.acog.org.

 

Sincerely,

/s/

Scott Hayworth, MD, FACOG

Chair

ACOG District II

 

Cc: Honorable Thomas K. Duane

Senate and Assembly Higher Education Committee members

 

 

The student midwife addressed their concerns in this letter to Richard Gottfried.

 

April 19, 2010

 

Honorable Richard N. Gottfried

New York State Assembly

822 Legislative Office Building

Albany, New York 12248

 

RE:  Letter of Concern Regarding ACOG District II Letter of Concern—Elimination of Licensed Midwife Collaborative Agreements (A.8117/S.5007)

 

Dear Assemblyman Gottfriend,

As a midwifery student, I would like to express my extreme gratitude over your legislation to eliminate the written collaborative agreement between obstetrician-gynecologists and licensed midwives. From a national perspective, this legislation is sensible, timely, and crucial to the health and survival of mothers and babies.

Our maternal health care system is already at risk.  In the New York City area, infant mortality rates range from 5 to 7 percent thousand births overall, though some neighborhoods within the boroughs exceed this. There are areas outside of New York City that also exceed this range: Cattaraugus, Erie, Monroe, Cayuga, Courtland, St. Lawrence, Broome, Columbia, Schenectady and Albany.  With abysmal infant mortality rates and Caesarean section rates up to 53 percent in parts of the state (i.e., Westchester), it is obvious why Amnesty International has recently called attention to the United States’ broken system.

Midwifery is a field separate from medicine. In New York State, midwives attend 11 percent of all births. In other developed countries with excellent birth outcomes, midwives attend 90 percent of all births with the other 10 percent delivered by ob-gyns, who are specialists in high-risk care. Midwives recognize the unique, complementary relationship between themselves and ob-gyns because midwives’ scope of practice is limited to normal, low-risk care; thus, high-risk cases are referred from the midwife to the ob-gyn.  This is part of the midwifery model of care and is a professional requirement. ACOG says that the written practice agreement enhances the relationship between midwives and ob-gyns, but for whom does it enhance the relationship?  What this written practice agreement does is continue to subjugate midwives to ob-gyns.  This has been an historic position since the establishment of nursing as a professional field of health. Keeping this written practice agreement affects all communities of women who aspire to be partners in their health care and not merely subordinate subjects incapable of assuming authority regarding professional and bodily autonomy.

The written practice agreement is not a prerequisite to being able to effectively care for the appropriate patient populations.  Midwives are restricted from practicing in the communities that most need their help not because of ambiguity, but because of the overgeneralization that the written practice agreement has worked “effectively and seamlessly.” There are midwives throughout New York State that are unable to practice because of the inability to find ob-gyns willing to sign agreements.  For now, these midwives remain anonymous because of the position of silence they are forced into in order to remain viable in the workforce.

The written practice agreement does not provide any guarantees for the potential high-risk situation because there is no requirement that the ob-gyn fulfill his or her obligation, or rather, there is no penalty for the ob-gyn’s dereliction of duty. Midwives depend upon ob-gyns in order to practice legally; therefore, this “agreement” is unilateral.  Agreements can only be entered when each party is a willing participant of equal status and equal decision-making abilities. Furthermore, ob-gyns use their increasing medical liability insurance argument as a barrier to signing practice agreements.  To “educate and inform” ob-gyns about the “importance of a written collaborative agreement” does not serve as a requirement that ob-gyns participate in said collaboration with midwives. Ob-gyns are influenced by local dynamics which include politics and economics. In that ob-gyns choose to care for low-risk women, midwives are their economic competitors. In the 15 states that have abandoned the written practice agreement, there are no issues with midwives obtaining liability insurance. Maternal health care providers are able to work efficiently and smoothly.

The New York State health care system may be implementing new practices, however the current statistics concerning maternal health care remain unacceptable.  The elimination of the written practice agreement cannot preempt collaborative model initiatives any more than the nonexistence of a written practice agreement between primary care physicians and specialists (i.e., cardiologists, gastroenterologists, etc.) limits their functioning, interactivity, and success. Ending the written practice agreement is the only way to move into a modern maternal health care system in which midwives are seen as equals with ob-gyns—each practitioner having expertise in his or her own field but with knowledge to share with one another in order to achieve the best outcomes for all mothers and babies.  Free the midwives.

 

Sincerely,

(Student Midwife)

 

Cc: Honorable Thomas K. Duane

      Senate and Assembly Higher Education Committee members