Healthcare

In Support of SB 1237: Lift the Physician Supervision Requirement for Certified Nurse Midwives

By: Clay Spence
By: Clay Spence

We agree with the Legislative Analyst's Office report’s finding that legislators should remove the physician supervision requirement on certified nurse-midwives. Removing physician supervision would not compromise on quality of care in low-risk pregnancies and normal births, would expand access to care in rural counties that need it most, and would save consumers and taxpayers roughly $1.2 billion over the next decade.

A certified nurse-midwife (CNM) has a master’s degree and is licensed to provide a variety of maternal health care services in hospitals, clinics, birth centers, and the home. There are currently 1150 CNMs in California, performing approximately 11% of all births in the state.¹ ²

In California, CNMs are supervised by highly paid Ob-Gyns who have a direct financial stake in restricting CNMs’ ability to practice independently or practice outside of a hospital setting. The supervision requirement is an example of how crony special interests can capture government at the expense of the general public. In this case the California Medical Association and the American College of Obstetricians and Gynecologists are fighting a measure which devolves power away from the healthcare establishment and allows qualified practitioners to compete on price and quality.

Under SB 1237, certified nurse-midwives will independently attend normal, low-risk pregnancies and births, and provide other maternal care services they have trained for. In addition to providing integrated, hospital-based care, they will be allowed to run out-of-hospital businesses such as birth centers and other innovative care models to meet demand and improve quality.³ CNMs will continue to collaborate with obstetricians to help ensure the appropriate level of care for atypical pregnancies – for instance, having twins or hypertensive disorders – and transfer patients to physician care when appropriate. Removing physician supervision will maintain quality of maternal care, increase access to care across the state, and drive down the cost of childbirth and associated perinatal costs.

Quality

As the California Legislative Analyst's Office report argues, removing supervision will not compromise quality of care, and may improve outcomes for many mothers.⁴ The most reliable meta-study of research on differences in care between nurse-midwives and obstetricians supports this conclusion.⁵ In addition, a recent national study on nurse-midwife “integration” – the degree to which nurse-midwives practice autonomously and at their full scope of practice – found that states with higher integration had higher rates of normal vaginal delivery and lower rates of preterm births and infant mortality.⁶

For the typical woman, nurse-midwife led care is often superior to obstetrician care. One reason is that nurse-midwives are trained to use medical procedures judiciously, and reduce the rates of unnecessary cesarean sections, episiotomies, and other invasive procedures. C-sections now occur during a third of all births and range up to 70% of births at certain hospitals, although there is no evidence that increased reliance on c-sections improves infant or parent mortality rates.⁷ ⁸ ⁹

Access

As the Federal Trade Commission notes, “Physician supervision requirements establish physicians as the gatekeepers who control independent access to the market.”¹⁰ It is thus no surprise that California is experiencing a serious shortage of maternal health care providers. Nine counties in California don’t have any ob-gyns, including Modoc, Trinity, Glenn, Colusa, Sierra, Yuba, Mono, Alpine, and Mariposa counties. At least five of these counties are designated as “maternity care deserts,” on account of lack of access to an obstetrical provider or hospital and limited health insurance.¹¹

Allowing nurse-midwives to practice at the level of their training would swiftly fill coverage gaps in many regions and go a long way towards establishing complete coverage in other parts of the state. While nurse-midwives attend approximately 10% of births nationwide, they attend 30% of births in rural areas.¹² A nationwide study of over 12 million births showed that in states that do not require physician supervision or collaboration agreements, the proportion of all births attended by nurse midwives is nearly 60 percent higher than states with such requirements.¹³ Furthermore, in states without supervision, the proportion of rural hospitals with midwife-attended births is significantly higher than states with supervision laws that strangle competition.¹⁴

As the LAO report points out, nurse-midwives are already filling a portion of the geographic access gap in California.¹⁵ In a free market, CNMs would do even more to establish independent and innovative practice models to meet demand in underserved areas.

Cost

CNMs currently attend 50,000 births a year, roughly 11% of the 470,000 babies born in California each year.¹⁶ Nurse-midwife led pregnancies and childbirths involve fewer invasive procedures and result in better outcomes than obstetrician-led pregnancies and childbirths. In particular, women in the care of nurse-midwives are less likely to give birth prematurely and use neonatal ICUs, and less likely to receive episiotomies, c-sections, and other expensive operations. For these reasons, nurse-midwife led births are on average $2,421 cheaper than obstetrician-led births.¹⁷

The same study found that private insurers would save about 2.5x as much as Medicaid programs by switching to midwife-led care. Half of California births are covered by MediCal and half are covered by private insurance.¹⁸ So the average savings to MediCal per birth switched to nurse-midwives is $1,383, and the average savings to private insurers is $3,458.¹⁹ Nurse-midwives are qualified to practice in any normal birth (between 50% and 75% of births), so by our conservative estimate, nurse-midwives attend about 21% of normal births in California.²⁰ Merely doubling this number to 42% of normal births would result in $34.6 million in MediCal savings a year, and $86.4 million in private market savings a year, for a total of $121 million in savings a year, or $1.2 billion over the next decade.²¹ ²²

For years, ob-gyns and hospital networks have suffocated competition in order to artificially boost their own bottom lines. SB 1237 will restore true competition to the maternal care industry, improving quality of care, access to care, and the cost of care. We urge California legislators to reject the physician supervision requirement and insist on certified nurse-midwives’ ability to compete on a free and open market.


[1] https://www.rn.ca.gov/pdfs/forms/survey2017npcnm-final.pdf
[2] http://california.midwife.org/california/files/ccLibraryFiles/Filename/000000000247/CNMFactSheet2014.pdf
[3] Contra the LAO report, we believe there is strong evidence that nurse-midwife care in an independent birth center setting improves outcomes: https://onlinelibrary.wiley.com/doi/pdf/10.1111/jmwh.12003
[4] https://lao.ca.gov/reports/2020/4197/midwives-031120.pdf
[5] https://www.whijournal.com/article/S1049-3867(11)00160-5/pdf
[6] https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0192523
[7] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3615450/
https://www.azdhs.gov/documents/preparedness/emergency-preparedness/pandemic-flu/az-pandemic-influenza-response-plan.pdf
[8] https://www.theatlantic.com/ideas/archive/2019/10/c-section-rate-high/600172/
[9] https://apps.who.int/iris/bitstream/handle/10665/161442/WHO_RHR_15.02_eng.pdf;jsessionid=BB3FD21DBBC2CD65516042188FD16E26?sequence=1
[10] https://www.ftc.gov/reports/policy-perspectives-competition-regulation-advanced-practice-nurses
[11] https://www.marchofdimes.org/materials/Nowhere_to_Go_Final.pdf
[12] https://www.cms.gov/About-CMS/Agency-Information/OMH/equity-initiatives/rural-health/09032019-Maternal-Health-Care-in-Rural-Communities.pdf
[13] https://lao.ca.gov/reports/2020/4197/midwives-031120.pdf
[14] https://www.ncbi.nlm.nih.gov/pubmed/27077363
[15] See Figure 10: https://lao.ca.gov/reports/2020/4197/midwives-031120.pdf
[16] https://www.cdc.gov/nchs/data/vsrr/report004.pdf
[17] https://www.phe.gov/Preparedness/international/Documents/napapi.pdf
[18] https://www.kff.org/medicaid/state-indicator/births-financed-by-medicaid/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D
[19] (MediCal savings + 2.5MediCal savings)/2 = $2,421; (3.5MediCal savings)/2 = $2,421; MediCal savings = $1,383 ; Private insurance savings = 2.5 * $1,383 = $3,458.
[20] https://lao.ca.gov/reports/2020/4197/midwives-031120.pdf
[21] This estimate for California savings is in line with national estimates, such as: https://www.sph.umn.edu/sph-2018/wp-content/uploads/docs/policy-brief-midwife-led-care-nov-2019.pdf
Experts estimate that reducing cesarean delivery rates in California alone would save between $80 million and $441.5 million annually: https://www.ncbi.nlm.nih.gov/pubmed/23090538
[22] Preterm births alone cost the United States $26 billion annually.

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