NYSALM Annual Reflection

We would like to take this opportunity to thank all the members of the board as well as all the other midwives and midwifery students who have volunteered their time and energy. For those of you who are new to our state organization – we welcome you!  You have joined at an exciting time filled with growth, activism and inclusion. 

Here are our major accomplishments, goals and priorities as we move forward together. And remember, we are a volunteer organization – with many of us working full time, raising families and teaching future midwives.

To begin, we share with you on the 46^th anniversary of Roe V. Wade, the Reproductive Health Act[1] has finally been passed by the NYS Senate. NYSALM has actively lobbied for this bill for the past 3 years.

1. The new law takes abortion out of the criminal code and puts jurisdiction of this under the public health law.
2. It protects the right to abortion in the first 24 weeks of pregnancy or later, if it is determined to be necessary for the health and safety of the mother.
3. It also adds a provision stating that any health care practitioner, licensed, certified or authorized under Title VIII or the education law may perform an abortion if it is within the scope of their practice.

The passage of this law expands our professional practice and autonomy. Under the leadership and close relationships NYSALM has built over our decades of work and determination with legislators around the state – especially with Assembly member Richard Gottfried – chair of the Assembly Health Committee, the RHA was passed.  We will continue to advocate for midwives to practice to the full scope of our profession. As we have learned, laws are one part of the work – developing regulations is where our work will continue.  

We also want to educate and inform our membership about our progress and full participation in centering midwifery care in this state through the development of regulations around midwife-led birth centers (MLBCs). Perinatal health care deserts exist throughout our state. NYSALM recognizes that midwives are a key strategy and solution to begin to address healthcare disparities – both rural and urban. In order to address this, though the midwifery-led birth center law was created in 2016, there has been a stalemate in creating just and reasonable regulations. The new standards for perinatal designation regulations begins with midwifery-led birth centers (MLBC) as the first level of maternal care. Under tremendous pressure from Gov. Cuomo, towards his legislative push at the end of 2018, NYS DOH finally made an earnest effort to begin the process of writing regulations– despite our persistent push to get these written in 2016 and 2017. Birth centers are a viable and necessary strategy for midwives to normalize and reclaim birth [2].  

Due to the relationships that have been persistently fostered by NYSALM, midwives are now vital stakeholders participating in numerous regional and state initiatives that directly address the pervasive maternal health disparities that plague our entire state – both in the city region as well as the many rural counties in northern and western NY. Our involvement includes:

1. Revision of perinatal designation regulations,
2. Addressing inequities in midwifery malpractice coverage and reimbursement,
3. Improving opportunities for midwives and student midwives of color,
4. Ensuring midwives are capable of practicing to the full extent of our education and training,
5. Active and inclusive participation in fundamental design of midwifery-led birth center (MLBC) regulations
6. Active leadership participation in Governor Cuomo’s Maternal Mortality and Racial Disparities Taskforce: Please note of the top ten recommendations of the taskforce – three directly involve/include midwifery as a core strategy to improve outcomes (see attached)

Our priorities are developed by membership past and present, and align with the priorities of ACNM. As we know – our numbers are small and our power is determined by your participation. Voter turnout as a whole within NYSALM and ACNM are frustratingly low, despite the fact that NYS is the second largest state affiliate of ACNM. When we are asked to take on the varied issues that continue to erode the rights of people – we feel just as passionate and do our best as a small volunteer organization. Unfortunately, participation at quarterly board meetings is also low. We strive to represent the diverse needs of the entire state.  As our mission states, NYSALM is dedicated to “ensur(ing) safety for the women and babies that reside here and who we serve” throughout this great state.

The work we do – to grow mothers/parents and families – is unending and requires grace, harmony and fortitude. There are many issues that we must address – autonomy, access, insurance, quality, education, diversity, choice – the list is endless – just as the attack on reproductive and human rights seems endless. We hope that we can unify our concerns and not diffuse them with rhetoric and displaced angst – as we are seeing on the national political front. We are not politicians, we are midwives – we trust the process, do the work and push when the time comes. Change is a long and arduous process.

Looking forward to 2019, here is what we will manifest:

1. Encourage the growth and participation of our membership throughout the state. We hope that those who have been members of NYSALM will continue to show up and turn out! And for those of you who know midwives who are not members – please encourage and support them to join and become involved.
2. Continue serving as primary stakeholders in local and statewide forums that are deeply and authentically engaged in addressing in improving the quality of maternal health care for all New Yorkers. This work is centered on addressing the maternal mortality and morbidity crisis that disproportionately impacts Black women.
3. We will continue to pursue our full practice autonomy as a central priority. Though MLBCs may not seem pragmatic – the reality is – it is another area of autonomy that we have reclaimed as THE guardians of birth. Every victory related to our autonomy matters. Ultimately, all our initiatives at NYSALM – with our volunteer energy – has been to increase our autonomy throughout the state. As we know, greater midwifery autonomy is directly tied to better maternal-child health outcomes. [3],[4] We are not doing this work alone – we have an active and dedicated board and always welcome more participation.
4. We also plan to address the greater dearth of the midwifery workforce in the large private Academic Research Centers (ARCs). Too often, our attention is shifted to the public health system – which has been a vanguard in New York – in terms of growing and sustaining its midwifery workforce, while large, well-funded private facilities are rarely questioned or pushed to open and grow midwifery services. In New York – the three major midwifery education programs – do not have midwifery services within their affiliated healthcare institutions – this seems deeply troubling and offers the potential to demand change. For example, in New York City, the ARCs (such as Columbia and NYU Langone) benefit from H+H mission to care for uninsured New Yorkers, people who are neglected by the private system. Please read this report for further reference[5].
5. Midwifery education is also a priority. Creating programs that require a DNP – will create further barriers to bringing our vision of a diverse profession to bear fruit.[6] This will serve as a barrier to diversifying our workforce and growing our profession. We need to invest in midwives from diverse racial, ethnic, gender and class backgrounds in order to truly take care of and represent all people. Kitty Ernst, a contemporary of Ruth Lubic, always reminds us “If we cannot produce the [nurse]midwives … we cannot be part of the solution to provide the quality, affordable, primary care needed by all women and childbearing families.” [7] If we are not invested in growing more midwives – are we truly committed to addressing racially driven health disparities? We proposed to the Governor’s office commit to offering eight midwifery scholarships for people of color– every year through the SUNY midwifery programs to promote further racial diversity within our profession.
6. Our partnership with ACOG District II – is a strategic partnership that creates a platform to nurturing greater practice collaboration with physicians. We are here to refine and uplift midwifery care in NY and hold our obstetrical partners accountable. We plan to also begin to build relationships with the local AWOHNN NYS chapter – as we know nurses are our colleagues and are vital collaborators.
7. We plan to continue to do the critical work of understanding our own biases and accept the exclusionary history perpetuated by ACNM midwives. The NYSALM board recently completed a course entitled “Power and Privilege in Midwifery” as a starting point to addressing the failures of our profession to uphold, center and celebrate midwives of color. We are proud that we have midwives of color leading our executive committee and serving on our board, but this is just the beginning of the work that we must ALL do to address the microaggressions, biases, prejudices and barriers that midwives and students of color regularly report with little to no compassionate change. [8]

We hear the membership asking for greater transparency, here is our vow to do so. Hold us accountable and push us to be better and stronger. NYSALM is committed to serving the needs of our membership so, please get involved. We set our agenda and we need unity and participation to speak truth to power. We look forward to an exciting year for midwifery and we hope this manifests in true and respectful dialogue within our small, but mighty community. Please join us on Feb 7 – for our first board meeting of 2019 – via Zoom video conferencing platform (check website for details)

Signed, Your NYSALM Executive Committee* (2019)

Ashley, Mimi, Pat & Sascha

*with additions & support from Karen J.

References

[1] www.nysenate.gov/legislation/bills/2019/s240

[2] Stapleton, S. R., Osborne, C., & Illuzzi, J. (2013). Outcomes of Care in Birth Centers: Demonstration of a Durable Model. Journal of Midwifery and Women’s Health, 58(1), 3–14. https://doi.org/10.1111/jmwh.12003

[3] Yang, T. Y., Attanasio, L. B., & Kozhimannil, K. B. (2016). State Scope of Practice Laws, Nurse-Midwifery Workforce, and Childbirth Procedures and Outcomes. Women’s Health Issues, 1–6. https://doi.org/10.1016/j.whi.2016.02.003

[4] Vedam, S., Stoll, K., MacDorman, M., Declercq, E., Cramer, R., Cheyney, M., … Powell Kennedy, H. (2018). Mapping integration of midwives across the United States: Impact on access, equity, and outcomes. Plos One, 13(2), e0192523. https://doi.org/10.1371/journal.pone.0192523

[5] Caress, B., & Parrott, J. (2017). On restructuring the NYC Health+Hospitals Corporation: Preserving and expanding access to care for all New Yorkers. New York. Retrieved from https://www.nysna.org/sites/default/files/attach/419/2017/09/RestructuringH%2BH_Final.pdf

[6] Wren Serbin, J., & Donnelly, E. (2016). The Impact of Racism and Midwifery’s Lack of Racial Diversity: A Literature Review. Journal of Midwifery and Women’s Health, 61, 694–706. https://doi.org/10.1111/jmwh.12572

[7] Ernst, K.  Letter from Kitty – Retrieved from https://portal.frontier.edu/web/fnu/message-from-kitty-ernst

[8] Goode, K. L. (2014). Birthing, Blackness, and the Body: Black Midwives and Experiential Continuities of Institutional Racism.

Governor’s Taskforce Recommendations

1. Establish a Statewide Maternal Mortality Review Board in Statute

New York State must establish a Maternal Mortality Review Board (MMRB) in statute. The MMRB will be comprised of a diverse group of experts that will assess the cause of each maternal death in New York State and identify and share strategies to prevent future deaths. The MMRB must have statutory protections to ensure accountability, reporting of its recommendations and full confidentiality protections as recommended by the Centers for Disease Control and Prevention (CDC).  Confidentiality allows for open and honest dialogue to analyze cases, determine if they were preventable and recommend strategies for prevention.

1. Establish a Grant Program for Pilot Hospitals to Administer Staff-Wide Training on Implicit Bias

Research shows that explicit and implicit biases are a regular part of the human experience, and many professions, including medicine, are impacted by implicit and explicit racial bias. Implicit bias has been documented to affect the patient-physician relationship as well as treatment decisions and outcomes. Racial and ethnic disparities in women’s health, including higher rates of maternal mortality and pre-term birth in black women, cannot be improved without addressing racial bias, both implicit and explicit. The creation of a grant program for hospitals to facilitate training for multidisciplinary providers to recognize their own racial bias and its impact on the delivery of care is necessary to understanding this issue and developing strategies to reduce the impact on patients.

1. Ensure Timely Access to Perinatal Quality Measures for Improvement

New York State must establish a robust data infrastructure to provide linked Vital Statistics and Statewide Planning and Research Cooperative System (SPARCS) data so all hospitals have timely access to perinatal quality measures stratified by race, ethnicity and insurance status. The program would be modeled after the California Maternal Quality Care Collaborative (CMQCC). A crucial part of this effort would be the New York State Perinatal Quality Collaborative (NYSPQC), which would be charged with working with hospitals on quality improvement (QI) efforts to address identified disparities in process and/or outcome measures. As envisioned, each hospital would have a quality and safety advisory board which would include community members, patients, providers and hospital representatives charged with implementing QI efforts to address disparities.

1. Provide Equitable Reimbursement to Midwives

Midwifery care has consistently shown improved outcomes for mothers and infants, particularly for those at greatest risk for healthcare disparities. Traditional fee-for-service Medicaid reimbursement in New York for midwifery care is 85% of the rate paid to physicians. Medicaid rates of reimbursement are used as the benchmark rate for commercial insurance negotiations creating inequity in reimbursement for qualified, licensed midwives. Given the transition to value-based payments, it is important that midwives be recognized as the primary care provider for women who choose them for their maternity care.  Midwives need to be recognized as primary care providers in maternity care, and as such, their reimbursement should be equivalent to all other primary care providers. 

1. Expand and Enhance Community Health Worker Services in New York State

Participants at the Commissioner’s Listening Sessions consistently expressed that community health workers (CHW) provide needed social support, information, advocacy and connection to services and are a trusted and valued community resource. In addition to CHW’s current scope of activities, participants identified opportunities to expand these activities to address barriers including: providing more childbirth education and support, assisting in the development of collaborative child care/social support networks, assisting with the development of a birth plan and supporting increased health literacy among the priority population.

1. Create a State University of New York (SUNY) Scholarship Program for Midwives to Address Needed Diversity

Although midwives serve large numbers of individuals from communities of color, the profession is poorly represented by people of color (14.5%). Women in historically marginalized communities report the value of having health care providers available who reflect their identity. These women report higher ratings of trust, satisfaction and uptake of provider recommendations – all key factors in reducing health disparities. Accordingly, New York State should create a SUNY Midwifery scholarship program to attract students of color committed to working with vulnerable communities throughout the State after graduating.

1. Create Competency-Based Curricula for Providers as well as Medical and Nursing Schools

To reduce maternal deaths and ameliorate group differences in outcomes, key Knowledge, Skills and Attitudes (KSAs) must be identified. Through broad expert engagement, a comprehensive set of measurable competencies will be identified for undergraduate, graduate and continuing education in areas of maternal health, social determinants, clinical care, quality improvement and implicit bias, with standards set by practitioner level. The competency set will be used to create field-tested tools to evaluate medical and nursing school curricula and to create psychometrically-sound assessments of learner outcomes. Results will inform undergraduate medical education (UME), graduate medical education (GME), continuing medical education (CME), and continuing nursing education (CNE) improvements. Competencies, curricula tools and learner assessments will be disseminated for broad use.

1. Establish an Educational Loan Forgiveness Program for Providers who are Underrepresented in Medicine (URIM) and who Intend to Practice Women’s Health Care Services

Establish an educational loan forgiveness program for health care providers who are underrepresented in medicine (URIM), licensed under Title 8 of the Education Law, and who commit to working within the maternal health field for a minimum of three years.

1. Convene Statewide Expert Work Group to Optimize Postpartum Care in NYS

The healthcare system is not currently designed to incentivize the delivery of quality, ongoing postpartum care that transforms into interconception and well woman care. To ensure women receive ongoing support during the postpartum period, New York State should convene an expert work group comprised of providers, payers, state agencies and patients to identify strategies to re-envision postpartum care as an ongoing process, rather than a single encounter, to foster individualized, woman-centered care and improve maternal health outcomes. The work group will identify the current barriers women face in accessing optimum postpartum care and propose practical solutions to address these barriers.

1. Promote Universal Birth Preparedness and Postpartum Continuity of Care for Women in Facilities Most Frequently Providing Obstetric Care for Black Women

Increase the outpatient capacity of obstetrics practices serving high volumes of black women to offer universal birth preparedness (classes, centering pregnancy, etc.), as well as screening for early identification of factors probably or definitely contributing to maternal mortality and morbidity, including underlying significant medical conditions such as previous complications of pregnancy, obesity, hypertension and stress.  In addition, include continuity of care options for antenatal and 4th trimester medical and mental health management, which may include closer coordination with a woman’s regular primary care physician, on-site, integrated chronic illness care and/or health home connectivity in preparation for enhanced and extended postpartum follow-up care to optimize health status post-delivery.