Most people are familiar with CNMs that deliver in a hospital setting. Hospitals are where most Americans feel most comfortable birthing their children in the 21st century. Whether you are a solo midwife working with a hospital to create midwifery hospital privileges for the first time or expanding a large midwifery practice that has been running for 20 years, there are always things to do to improve access to your services.
Midwives working within the healthcare system and having direct access to obstetricians in emergency situations do have some advantages compared to out-of-hospital midwives. There are also some challenges. Many hospitals have written policies and procedures that are restrictive of midwifery practice, and the practice needs to be aware of these resources. If the medical atmosphere isn’t midwifery-friendly, there can be tension in the unit with nurses and other doctors practicing. The practice’s care may need to be extra careful about who they accept as a patient and thoroughly chart to protect their decision-making for the patient.
There are some areas around the country where midwives are independent and have a wonderful collaboration with hospitals and physicians to refer to. Know your community, state laws, and medication community environment. Hospitals are a great place for women to get their first taste of what a midwife is (delivering in a setting they are familiar with but testing the waters of traditional medicine by choosing a midwife).
Billing is usually easier for a hospital-based practice. There are no supply codes or facility fees to worry about (the hospital covers that portion of the insurance charges). Midwife bills only for services rendered (maternity care, hospital visits, newborn care, or procedures like non-stress test interpretation or circumcision). Most insurance plans will cover a CNM delivering in a hospital setting since this is the mainstream option for birth.
The volume of midwifery practice tends to be similar to a doctor’s volume (8–10 births per month per midwife). The reason for this higher volume of practice is overhead costs. The hospital is billing for charges that a birth center would get paid for. A midwife’s salary with benefits is usually a good chunk of the monthly overhead expenses. Supplies and additional services offered with hospital charges can be billed separately with an out-of-hospital practice to help create a lower patient ratio per midwife.
The benefit of having a hospital practice is that one midwife can be on call and cover the entire unit. The nursing staff provides the labor support, and the midwife can choose to come for just the delivery portion rather than as soon as the patient is admitted.
The hospital midwifery team usually has a couple of midwives on call and more demands for time with patients. The midwife usually comes to the patient’s home or meets at the birth center at the same time the hospital patient is admitted. Demands for labor support are more involved in out-of-hospital settings, hence part of the lower volume as well.
Hospital-based midwifery practices tend to take higher-risk patients than their out-of-hospital counterparts. That increases liability risks and the chances of poorer outcomes. Especially in a small, community hospital, anything can come through the door and needs to be cared for. I have seen many CNMs really collaborate well with other practices that have privileges by offering their First Assist training during cesarean sections for other doctors and covering calls during times of shortages to show their benefits on many levels.
When a midwifery practice can create relationships and perceived value for hospital organizations and patients, that team will have long-term success no matter where in the US the hospital-based midwifery practice is started. Midwives are vital as the shortage of obstetricians is getting worse. Brag about your positive points to hospital administration, insurance companies, and already-established doctors.
Once the financial benefits, maternity and neonatal outcome benefits, and resource benefits available with hospital midwifery teams are shown, any hospital will be busting at the seams to have this team deliver their babies. I have seen hospitals double and triple their delivery quota for the month, adding a great midwifery team. I have seen the opposite occur. A well-established and respected midwifery team is “letting go” due to a new administration or collaborating doctor retiring, and the birth number falls dramatically at that hospital.
Midwives have the power to change hospital norms. It is a harder place to practice compared to out-of-hospital groups since so many policies are based on litigation and high-risk situations, but it is also the place where the greatest impact on the community takes place!