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Re: Midwifery Care and Birth Outcomes in USAFrom: Betsy Hyde (elishyde@connix.com)Wed Aug 12 22:42:12 1998
At 9:24 PM 8/12/98, Garry E. Siegel, M.D. wrote: >I have not read the article, but were the MD deliveries *Obstetricians* >or physicians (ie likely a mix of Ob docs, FPs, and even general >practice MDs)? > >This might make a difference. > >Garry > the study analyzed *all* the CNM attended singleton vaginal births between 35-43 weeks in 1991. These births were compared to a random sample (25% of *all* physician attended births) during the same time period. There was no attempt to distinguish obstetrician from FP/GP attended births. However, since the physician attended singleton vaginal births had N= 2,634,550 vs N3,194 for the CNM singleton vaginal births during the same gestational age, I doubt that differences between obs/FPs/GPs are significant. My assumption, and it is just that, is that there are more ob/gyns attending births than gps/fps. Correct me if I am wrong. I originally posted this study for comment. My intent was not a *one-ups-manship*. Nor was it an attempt to divide the list into teams ("I'm better than you"). This should never be our point. (At least it is never *my* point. If y'all wanna pick teams, that's your problem.) I could not practice without the support and skills of my obstetrician colleagues. Nor could they practice without me.And they will be the first to admit that!! That is why we are in a collaborative practice, and that is why our outcomes are as good as they are. Collaboration works. This is one of the reasons why midwifery stats are as good as they are. We are not practicing in a vacuum..... CNMs are not required to be *supervised* by obstetricians. We are required to have a collaborative practice relationship. However, CNMs are defined as being independent practitioners, who practice in a health care system which provides access to physician collaboration, consultation and referral. And this is how it should be. But, at least in our practice, I am considered an independent practitioner....I consult as necessary, but am not supervised when women are essentially uncomplicated. Today I saw 26 ob and gyn clients. I am not happy w/ this number.Clearly, it is not the ideal number. It is kind to neither midwife nor patient. But that is just the way it is in our practice, thanks to HMOs. Among the ob patients was a 17 yo G4P1, twins 31 weeks, hct 26, chlamydia x4, boyfriend in jail. Made plans to give her depo PP.Checked fe intake, set up BPPs for next week.babies s=d, no discrepancy. Saw G 13, P1, TAB 11. One hour glucose screen 270. Went over insulin, diet, pprandial glucose, BPPs etc. Discussed family planning. Also saw a late registrant (24 weeks at first visit) w/ platelets 48K. No bruising, no epistaxis. Made sure she had f/u with both hematologist and perinatologists. Discussed labor management. Discussed bone marrow bx results. Made sure she kept her f/u appt w/ perinatologists re PUBs and ? steroids. Saw 26 weeker w/ BRB per vaginum. Saw class B diabetic...sugars were good. BPP fine. Saw 26 weeker w/ heavy BRB, U/s low lying placenta. Saw a gyn w/ lupus flares, high steroids, and recurrent yeast. saw gyn w/ Frederick's (?sp?) ataxia ,300 lbs, amenorrhea on OCPs. Took 3 nurses to help me position her for pelvic.....and then the cyto fixative spritzer was dead, so had to repeat the whole thing. Grand multip, orthodox Jew, C/Sx1, VBACx6, wanted to discuss labor management. And these are the patients I remember....... CNMs do not, as one of you have said, need to practice with physician supervision. Many of us practice in collaborative practice relationships,but, at least in my state (Connecticut) there is no legislative nor practice statement which requires *supervision* by our physician colleagues. Indeed, CNMs may form their own PCs and hire their physician consultants. CNMs must have a clinical practice relationship with a physician. This is appropriate, IMO. There are many times in which I collaborate, consult or refer to the obs with whom I work. But there are also many times they send patients to the midwives. This is the nature of collaborative practice. Please, let us not take this into a them vs us flame war. That benefits neither us, our clients, the list or life in general. And it wastes band width. And it give me a headache. My original point was simply to state that midwives are safe, appropriate practitioners, and that we have good outcome data to support our practice. I posted this article from the Journal of Epidemiology and Public Health to reiterate the safety of midwifery care. I would be happy to foward this and a bibliography on midwifery care to whomever wants its. IMO, collaborative practice w/ obstetricians and midwives is the most appropriate form of practice.
-- Betsy Hyde CNM Midwife in collaborative OB/CNM practice Assistant Clinical Professor/Yale University
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