Throwing out the baby with the bathwater

World Health Day is April 7, 2005. The World Health Organization sponsors this day every year to promote world awareness of an international health problem. This year, WHO is focusing attention on mothers and babies. “Make Every Mother and Child Count” is the theme of World Health Day. How fortunate that WHO is turning the spotlight on babies and the women who birth them at a time when the CNMI is facing a potential catastrophe in its maternal/child health care delivery system. How fortunate that we can pause and examine what is about to happen before it happens. Perhaps we can correct it before it is too late.

Babies and their mothers are the world’s most precious commodity. Within each newborn babe is an unlimited potential to change the world for the better. Babies bring love and joy to their families, strengthen their communities, and give the world hope.

The Commonwealth Health Center is in the baby business. More than 1,200 babies are born within its walls each year. The midwives who attend to and deliver the vast majority of these babes under the supervision of obstetricians are as culturally diverse as the birthing mothers. Set up many years ago, the model of care (or how health care is delivered) is based on a British model in which the midwives provide all of the nursing and midwifery care to the women giving birth under the supervision of obstetricians. Most of the midwives are originally from Fiji and have practiced midwifery on Saipan for many years. However, times have changed and we are about to witness the exodus of the Fijian midwives. I am worried about the ramifications caused by their departure and how this may impact the health and well-being of women and children in Saipan. My conscience dictates that I share my concerns with the community before it is too late.

All of the midwives employed by the Commonwealth Health Center’s hospital division have specialized training in midwifery as well as years of experience whether they were previously registered nurses who passed the NCLEX, were “grandfathered” into the licensure process, or have endorsement from the midwifery education program in Fiji. In fact, all but one midwife currently practicing in the labor & delivery unit of CHC received their midwifery education in Fiji.

After many years of renewing the nurse-midwifery licenses of the Fijian midwives, the CNMI Board of Nurse Examiners has dictated that the midwives are nurses who must pass the U.S. credentialing examination for registered nurses. The NCLEX does not certify midwives and does not examine the core competencies (the skills and knowledge base) of midwifery as set out by the International Confederation of Midwives or the American College of Nurse-Midwives. The NCLEX is designed to test the entry-level nursing competence of candidates for licensure as registered nurses and as licensed practical/vocational nurses—not midwives. Midwifery includes some nursing knowledge and skills, but midwives can and do practice as midwives without being nurses all over the world. U.S. certification as a registered nurse is not necessary for a midwife to safely practice midwifery. While the NCLEX is an appropriate tool for setting standards for professional nursing at the entry level, it is an inappropriate tool with which to certify midwives to practice midwifery. The NCLEX does not address the competencies of midwives and does not adequately assess the skills and knowledge base of midwives in their areas of practice.

It is a case of apples and oranges: while both are fruits and taste sweet, they are inherently different. Neither the apple or orange is better than the other; they share some commonalities, but key differences exist that make one an apple while the other an orange. The Fijian midwives, like other midwives, are experts in normal labor and birth and work very well with the obstetricians in caring for women who are experiencing high-risk or complicated pregnancies and births. In this setting, they work under the supervision of obstetricians and focus their practice on normal birth and in-hospital care of the high-risk pregnant woman. Their experience and dedication are priceless.

The International Confederation of Midwives, the International Federation of Gynecology and Obstetrics, and the World Health Organization define a midwife as:

A midwife is a person who, having been regularly admitted to a midwifery educational programme, duly recognised in the country in which it is located, has successfully completed the prescribed course of studies in midwifery and has acquired the requisite qualifications to be registered and/or legally licensed to practise midwifery. She must be able to give the necessary supervision, care and advice to women during pregnancy, labour and the postpartum period, to conduct deliveries on her own responsibility and to care for the newborn and the infant. This care includes preventative measures, the detection of abnormal conditions in mother and child, the procurement of medical assistance and the execution of emergency measures in the absence of medical help. (ICM, WHO 1972)

The licensure issues surrounding the Fijian midwives could be easily remedied by simply licensing them as midwives under the CNMI BONE. This licensure change could deflect any and all disputes with any national organizations with which the BONE is associated. Fijian midwives could be licensed and regulated by another supervising board, if necessary. Competency-based assessments and continuing education requirements could be mandated to ensure up-to-date, high quality care.

According to the WHO, the midwife appears to be the most appropriate and cost effective type of health care provider to be assigned to the care of normal pregnancy and normal birth, including risk assessment and the recognition of complications. Among the recommendations accepted by the General Assembly of the XIII World Congress of FIGO (International Federation of Gynaecology and Obstetrics) in Singapore 1991 (FIGO 1992) are the following:
* To make it more accessible to women in greatest need, each function of maternity care should be carried out at the most peripheral level at which it is feasible and safe.
* To make the most efficient use of available human resources, each function of maternity care should be carried out by the least trained persons able to provide that care safely and effectively.

Replacing the Fijian midwives is not an easy task. Despite recruitment efforts, no one has been hired to replace these exiting midwives. The CNMI Department of Public Health administration is examining the possibility of the physicians (obstetricians and private practice doctors) delivering every baby born at CHC. While the hospital averages four births per day, in reality, more than one delivery often occurs simultaneously which would create a potentially dangerous situation for one physician and increase the risk of birth in the absence of a qualified attendant as well as other serious problems. In addition, the obstetrician on-call for deliveries is also the doctor who performs cesarean or surgical deliveries and must be available to the Emergency Department for consultation and management of emergency cases related to female reproductive health. The Fijian midwives may be replaced with nurses who would require extensive training and experience in maternity care at the standard of care we enjoy on Saipan. Recruiting nurses from the mainland or other countries would increase costs of providing care and these nurses would definitely require NCLEX certification. Recruiting nurses who are already experienced and able to function at the standard of care we currently enjoy at CHC is cost-prohibitive and very difficult. Using this model of care, more obstetricians would be required, further increasing costs of providing care to the childbearing population and increasing an already heavy burden on the government and DPH to fund health care.

According to the U.S. National Institute of Medicine in its report, Improving Birth Outcomes (2003), determining the best model of labor and delivery care for a particular setting and the most effective and efficient steps to reach it should be based on the model’s clinical-effectiveness and cost-effectiveness, feasibility, and family/patient acceptance in the community. I believe it is important to note, on a cultural and woman-centered focus, that Saipan currently has no female doctors delivering babies at CHC. Effective obstetric and neonatal services depend on skilled care at each delivery and, in the case of complicated deliveries and high-risk medical conditions of the mother and/or fetus/neonate, access to high quality specialist care and management. Obstetricians are best utilized to manage complicated and high-risk pregnancies and deliveries and to supervise the overall maternal/fetal health delivery system. In well-functioning health care systems, normal births are supported but not overmedicalized, limiting costs and reducing the risk of iatrogenic complications, while complicated births receive prompt, appropriate treatment. In addition, the Institute also recommends that, to improve birth outcomes, health care leaders must identify the interventions, programs, and strategies likely to have the greatest impact on maternal, fetal, and neonatal morbidity and mortality and these leaders must allocate the resources needed to achieve a successful result. Increasing costs by increasing the number of specialist physicians to provide care to a largely normal population of childbearing women and their newborns is not an evidence-based method of providing high-quality, fiscally-responsible maternal/child health care.

Why are we changing a care delivery system that isn’t broken? Why are we throwing out the baby with the bath water? What does this mean for the women and babies of Saipan?

The health and well-being of mothers and children is a commonly-used health indicator of a community. If our mothers and babies do not suffer severe complications or death related to pregnancy and childbirth, our report card looks good—usually As and Bs. How women and children fare through pregnancy and birth is like a picture of how we are providing health care to the community in general. These statistics are the report card of whether or not the quality of care meets our standards of care as well as the needs of the population. When the number of maternal, fetal, neonatal and infant complications and deaths associated with pregnancy and childbirth increases, we know we have a problem.

Let’s not wait for the failing report card.

Rather, let’s address the situation before it happens and retain the Fijian midwives. Let’s go forward, not backward. Let’s examine how we can develop a framework or strategy to improve on our current maternal/child health care services to bring an even higher level of care to our most precious and priceless commodity—the babies and the mothers of CNMI.

Latisha Lochabay MSN, CNM
Saipan