Most people are familiar with CNMs that deliver in the hospital setting. Hospitals are where most Americans feel the most comfortable birthing their children in the 21st Century. Whether you are a solo midwife that working with a hospital to create midwifery hospital privileges for the first time or expanding a large midwifery practice been running for 20yrs, there are always things to do for improving 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 too. Many hospital 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 on the unit with nurses and other doctors practicing. The practices care may need to be extra careful 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 hospital and physicians to refer to. Know your community, state laws, and medication community environment. Hospitals are a great place for women to get first taste of what a midwife is (delivering in a setting they are familiar with, but testing the water 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 (hospital does that portion of insurance charges). Midwife bills only for services rendered (maternity care, hospital visit, newborn care, or procedure like Non-stress Test interpretation or circumcision. Most insurance plans will cover a CNM delivering in the hospital setting since this is teh main stream option for birth.
The volume with a midwifery practice tends to be similar to a doctor’s volume (8-10 births/month per midwife). Reasoning for this higher volume practice ratio is overhead costs. The hospital is billing out for charges that a birth center would get paid for. Midwife 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 benefits of having a hospital practice is one midwife can be on call and cover the entire unit. The nursing staff provides the labor support and midwife can choose to come for just delivery portion versus as soon as patient is admitted. With out of hospital midwifery team, usually have couple midwives on call and more demands for time with patient. The midwife usually comes to patient’s home or meets at birth center same time hospital patient would be admitted. Demands of labor support are more involved with out of hospital setting hence part of the lower volume as well.
Hospital based midwifery practice tend to take higher risk patients that their out of hospital midwifery counterparts. That increases liability risks and 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 priveleges by offering their First Assist training during cesarean section for other doctors and cover call during times of shortages to show their benefits on many levels.
When a midwifery practice can create relationships and perceived value for hospital organization and top of 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 seam 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. Well established and respected midwifery team is “let go” due to new administration or collaborating doctor retiring and birth number fall 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 place where greatest impact on community takes place!