CNM/MD RELATIONS

Cultivating Mutual Respect

Authors


The value of nurse-midwives' contributions to the health care of women and infants has been receiving greater and greater recognition from physician colleagues over the decades. In 1986, physician responses to an attitudinal survey were quoted in Nurse-Midwifery in America (1); more gratifying words of praise and appreciation for nurse-midwives would be hard to imagine. The number of physicians seeking midwives to join their practices has also increased markedly over the years. And yet, the daily experiences of some midwives clearly prove to them that the problem of physician-midwife conflict is far from a historical one.

Many of us have experienced the frustrations and complexities of midwife-physician conflict first-hand and have struggled to overcome them with varying degrees of success. Our goal has always been simply to practice our profession unhindered by arbitrary restrictions, secure in the knowledge that we have been well educated in the provision of safe and personalized health care to women and infants and confident of our ability to give that care. The corollary to this, of course, is our confidence that we have become experts in the care of normal women. We have also finetuned our skills at recognizing deviations from the normal so that we can appropriately collaborate with our physician colleagues. We are the first to acknowledge our debt of graotude to our consultants when they come to our assistance with the management of a situation that has gone beyond the range of normal as defined in our practice agreements. But how long is it going to take before we are recognized as competent, not only to detect and report these deviations, but also to practice the full scope of our profession unimpeded as long as normalcy prevails? Is it not yet time to accord us the full recognition we have painstakingly earned as experts in the care of well women?

What some CNMs find most frustrating is that the professional respect we accord our physician colleagues is not always reciprocated; instead, we are forced, all too often, into a defensive posture, struggling to prove that we share the same goal—that of delivering the best and safest possible health care to women. Professional distrust may take many forms, but the end result is always the same: Distrust breeds distrust, collaborative teamwork breaks down, and the very people we are committed to serve—caught in the middle of internal strife—are in danger of receiving a poorer quality of care. Having to resign themselves to being always on the defensive might make some midwives feel that they must resort to subterfuge, such as concealing lengths of second stages or closing the labor room door to prevent interference. What long-range toll might this take from the standpoint of professional dissatisfaction and burnout? Could clients be deprived of the skills midwives excel at—ambulation in labor, alternative positions for delivery, oral hydration, to name a few—just because the midwife has given up the fight?

That battles are still raging on some fronts is all the more ironic in the light of the landmark studies of nurse-midwifery care that have gained wide recognition, with impeccable statistics clearly demonstrating the superior outcomes that our care produces. Five of these studies, which ought to be familiar to all of us, are summarized in the ACNM's recent fact sheet, Contributions of CNM's to Improved Health Care Outcomes (2). The studies, dating from the 1960s and 1970s, concerned the increased utilization of CNM services in providing prenatal care to high-risk groups of women. The incidence of low birth weight, prematurity, and neonatal death dropped significantly. That this was no coincidence is most clearly shown in the Madera County, California, study, where the improvements brought about by the midwives' care were completely reversed when the midwife program was discontinued due to the California Medical Society's opposition to the legalization of nurse-midwifery (3).

Another study that must become part of the repertoire of every CNM appeared in the New England Journal of Medicine in December 1989 (4). This is the National Birth Center Study, “Outcomes of Care in Birth Centers,” with three nurse-midwives (including the first author) among the six authors. In this study of 11,814 women admitted to 84 freestanding birth centers, with nurse-midwives providing the care in 80% of the births, the intrapartum and neonatal mortality rate was 1.3 per 1,000 births, the cesarean section rate was 4.4%, and there were no maternal deaths. This is a stunning demonstration of the safety and efficacy of nurse-midwifery care. Similarly, the Journal of Nurse-Midwifery has published several papers throughout the years, which document the contributions of CNMs to improved health outcomes among mothers and babies (5–22).

No survey of excellent nurse-midwifery outcomes would be complete without specific mention of North Central Bronx Hospital, the prototype of a nurse-midwifery-run tertiary care service for inner-city clients where physicians provide consultation under the direction of the midwives (7). Their statistics remain consistent with their impressive beginnings; over the past three years, the midwives delivered over 85% of the more than 3,000 deliveries per year, with their cesarean section rate remaining under 12% and the stillbirth rate around 1% (P. Elsberry, CNM, personal communication, 1991). This client group is not a handpicked low-risk population, but it is composed of every woman who registers for prenatal care, as well as those who first appear on the doorstep after labor has begun.

The editors of Nurse-Midwifery in America (1) explored the issue of physician opposition to nurse-midwifery practice, listing several areas of conflict, the main ones being the perceived economic threat and the unfamiliarity of doctors with our profession. Another possible explanation lies, at least in part, in the prevailing system of medical education in some of our hospitals. In these years on the front lines, young residents, often short on sleep and eating erratically, must assume more responsibility than they have ever imagined humanly possible. They are grilled daily on the various cases in which they are involved; if an outcome is less than optimal, they carry with them a real dread of similar outcomes in the future. Some begin to practice defensively, perceiving each management situation as a potential catastrophe until proved otherwise.

Young doctors may also suffer from a competitive sort of territoriality; this is particularly true of those whose professors and preceptors have taught them that there is only one right way to practice obstetrics. When another kind of care provider (with less education!) presumes to manage things a different way, and, even worse, seems to be succeeding at it, they may feel threatened; some may respond by trying to impose their will on the midwife regardless of whether or not the management is proceeding smoothly. In all fairness, many of them, in their inexperience, sincerely believe what they have been taught; some may practice that way all of their lives, whereas the more open-minded are usually convinced later by their well-educated private patients (or by contact with midwives) that, indeed, there is more than one way to achieve the same desirable outcome.

What, then, can we do to advance professional rapport and facilitate good working relationships with physicians and other health care providers who share our goals, while at the same time preserving our autonomy and integrity? The editors of Nurse-Midwifery in America (1) proposed several solutions, most of them involving the education of physicians about nurse-midwifery and our special skills, emphasizing our unique contribution and the fact that our profession is complementary to, not competitive with, the[Text missing in PDF]. These suggestions have already been implemented in many settings. Indeed, some CNMs have received appointments on medical school faculties, providing clinical and classroom Instruction to medical students and residents and participating as full members of the team in conferences, rounds and seminars. Medical students and residents in some places have even been spotted carrying copies of Varney's textbook Nurse-Midwifery (23) around the hospital corridors.

Those of us working in settings where CNM/MD relations continue to be strained should not despair; the trend of the times is in our favor, with our cost-effectiveness being ever more emphasized and our desirability more and more publicized. We must staunchly, cheerfully, and courteously continue to defend our place in our chosen field, negotiating when necessary with minimal compromise, invoking the ACNM's Standards (24} as well as our own criteria for professional practice. Recognizing that our record of superior health care outcomes is a direct result of the application of principles based on the midwifery model, we should design or revise our protocols to include the freedom to practice our unique midwifery skills. At North Central Bronx Hospital, for example, where the official philosophy of the Department of Obstetrics/Gynecology is one of “shared control,” the protocols specifically state that alternative management options shall be employed unless there is a definite indication to use a more technical one, and such use must be justified (P. Elsbeny, CNM, persons! communication, 1991). And, as we work to maintain the standards of our profession, we must continue to document our successes to ensure our professional credibility now and in the future.