Currently, only Certified Nurse Midwives (CNM) are the only legally-enabled professional midwife type who can practice in Ohio. As established in Ohio Revised Code (ORC) Section 4723.41, there are several requirements for CNMs, including licensure as an advanced practice nurse and an application to practice in the specialty and pay a license fee.[1] Also, as a provider designated in Ohio’s state Medicaid plan, CNMs are eligible for Medicaid reimbursement.
Certified Nurse Midwives are eligible for Medicaid reimbursement.
Under Ohio Administrative Code (OAC) Section 3701-83-33 to 42, which outlines the regulatory definitions for the establishment of freestanding birth centers, the following represent the other categories of midwives in Ohio.[2]
TABLE 1: Midwife Definitions in Ohio Law
Unlike other states, Ohio notably does not define a Certified Midwife (CM). Developed in 1994 by the American College of Nurse-Midwives, the CM credential expands access to midwifery through multiple educational pathways. The CM pathway includes a graduate degree in midwifery (where Certified Professional Midwife (CPM) does not) and has many of the same regulatory requirements as CNMs, only lacking the nursing credential.[3] Additionally, Ohio CNMs have limited prescriptive authority; do not have autonomous practice and risk assessment authority (i.e. physician oversight is required and CNMs do not have the ability to practice independently); do not have a stand-alone regulatory board; and are functionally unable to petition consultation and referrals outside of institutional settings (i.e. freestanding birth centers and home-based deliveries). Beyond CNMs, then, the de facto professionalization of CMs and CPMs does not exist in Ohio. As such, legal midwifery is thereby under the functional authority of hospitals, meaning deliveries are compelled into institutional settings versus community-based or home-based settings.
How are freestanding birth centers regulated in Ohio?
Given the role freestanding birth centers have as a regulatory source for midwifery, looking into Ohio’s laws regarding these facilities is worthwhile. OAC sections 3701-83-33 to 42 outline how freestanding birth centers are regulated. It should be noted that freestanding birth centers are called freestanding because hospitals commonly describe maternity wards’ birthing suites as “birthing centers” though they are not the same thing. These, instead, are hospital facilities that are licensed under the auspices of the hospital. For freestanding birth centers, there are requirements regarding the definition of risk, professional types, reporting, facility requirements, and medical oversight in each section. Key to these standards are the requirements to establish physicians as medical directors and consulting physicians, and additional requirements for transfer agreements must be in place with hospitals.
Ohio’s current delivery landscape appears to be more institutional than collaborative.
According to the American Association of Birth Centers, these requirements mean birth centers “frequently operate in a needlessly restrictive regulatory environment which is often exacerbated by hostile or exclusionary practices on the part of dominant provider groups, health plans and other payers and professional liability insurers.”[4] The argument the association outlines is that licensure does not provide a pathway to the establishment, but rather medical oversight becomes a tool to create barriers of entry for community-based providers, thus preventing centers from existing meaningfully. In other words, physicians and hospitals can refuse to collaborate with centers. There are also concerns for potentially interested physicians that liability insurance is too expensive. With the increase of physicians employed by hospitals, hospitals prevent physicians from overseeing deliveries in locations outside of the hospital as a matter of contract. Even though there is evidence from the American College of Obstetricians and Gynecologists that improved collaboration produces better outcomes and that independent midwives in clinical decision making do not adversely impact results, Ohio’s current delivery landscape appears to be more institutional than collaborative.[5],[6]
Comparative analysis
Depending on the state, the scope of practice for CPMs varies widely.[[7]](https://www.ama-assn.org/sites/ama-assn.org/files/corp/media-browser/specialty group/arc/direct-entry-midwife-state-chart-practice-information-2016.pdf) Registrations, accreditation bodies, educational requirements, a regulatory board's presence, and testing requirements are all variables in a given state’s regulatory approach. Notably, 21 states provide CPMs some ability to administer medications, though the type of medications they can prescribe and the potential for oversight also varies widely. Given this broad variability, it’s important to gauge the relationship between a given state’s regulatory structure of midwives and the outcomes associated with deliveries, generally.
In 2018, a multidisciplinary team of maternal and infant clinical experts produced a study called the Access and Integration Maternity Care Mapping (AIMM) Study. The point of AIMM was to evaluate the statistical relationship between the including midwives in the delivery process and assess the impact. Through this work, the group developed the Midwifery Integration Scoring System (MISS), where higher scores indicate greater integration of midwives across all settings. Using reliable indicators in the Centers for Disease Control and Prevention’s Vital Statistics Database, the MISS identifies the correlation coefficients between scores and maternal-newborn outcomes by state. While no state achieved a perfect score of “100” (the highest was Washington state at 61), Ohio ranked 46th out of 50 states with a score of 20. The tool breaks down the score into four main areas:
- Options for the birth site (16 measures, 25 points)
- Reporting and data collection (1 measure, 1 point)
- Vaginal Birth After Cesarean (VBAC) allowed for licensed midwives (1 measure, 3 points)
- Professional standards for CNPs, CPMs and CMs[8] (For each: 11 measures, 24 points)
- Regulation & Medicaid reimbursement (3 measures, 8 points)
- Autonomous practice & risk assessment (3 measures, 7 points)
- Scope of practice (2 measures, 2 points)
- Medication administration authority (2 measures, 5 points)
- Is representation on the regulatory board required (1 measure, 2 points)FIGURE 1: Relative Integration MISS Score
- TABLE 2: MISS Score By Category
- As the MISS indicates, Ohio lags the country in midwife integration across many measures. Notably, for Ohio, CPMs and CMs are not integrated at all and, even for CNMs, the biggest areas of deficiency are in midwife autonomy. This deficiency is represented in the requirements for CNMs to have physician oversight, a consultation agreement (which is particularly difficult to achieve in home or center settings), access to medications and prescription-writing authority.
Ohio lags the country in midwife integration across many measures.
Cost benefit
Beyond the benefit in outcomes, cost savings are apparent when midwife legalization is made possible in de-institutionalized settings. Currently, expenses associated with normal delivery and Caesarean sections vary widely in Ohio and across the United States, especially when compared to other industrialized nations.[9] This variance is difficult to explain in concrete terms, but the expense generally is driven by an institutional approach to delivery.
As complex medical facilities, tertiary medical centers like hospitals have high fixed costs with high salaried practitioners, complex equipment and large campuses with significant infrastructure. While there is certainly an advantage to this for high-risk medical interventions, it’s important to realize that the entirety of a hospital’s resources are not always necessary for effective, efficient delivery. This supposition is borne out in the data as well, which suggests services for low-risk births are significantly less expensive when performed by a midwife. For example, in a 2019 University of Massachusetts study, researchers found that childbirth costs for low‐risk women with midwife‐led care were, on average, $2,262 less than births for low‐risk women cared for by obstetricians.[10] Similarly, in a 2019 study from the American Journal of Managed Care, data from 2010 indicated average facility charges for freestanding birth centers were $2,277, while hospitals charged an average facility fee of $10,166 for an uncomplicated vaginal birth – an 87.7 percent difference. In Ohio, the average price for normal delivery is $16,106.
[1] Requirements for practicing nurse-midwifery or other specialty. Ohio Revised Code §4723.41 (2018). https://codes.ohio.gov/orc/4723.41v1
[2] Definitions – exempt freestanding birthing centers. Ohio Administrative Code §3701-83-33 to 42 (2016).
[3] Comparison of Certified Nurse-Midwives, Certified Midwives, Certified Professional Midwives Clarifying the Distinctions Among Professional Midwifery Credentials in the U.S. (2017, October). Retrieved March 11, 2021, from https://www.midwife.org/acnm/files/ccLibraryFiles/FILENAME/000000006807/FINAL-ComparisonChart-Oct2017.pdf
[4] Rathburn, L., MSN, CNM, FNP. (2014, April 30). FTC Health Care Workshop, Project No. P131207 [Letter to Mr. DonaldS. Clark, Secretary, Federal Trade Commission]. https://www.ftc.gov/system/files/documents/public%5Fcomments/2014/04/00171-90023.pdf
[5] Zolkefli, Z. H. H., Mumin, K. H. A., & Idris, D. R. (2020). Autonomy and its impact on midwifery practice. British Journal of Midwifery, 28(2), 120–129. https://doi-org.proxy.library.ohio.edu/10.12968/bjom.2020.28.2.120
[6] Lotshaw, R. R., Phillippi, J. C., Buxton, M., McNeill-Simaan, E., & Newton, J. M. (2020). A Collaborative Model of a Community Birth Center and a Tertiary Care Medical Center. Obstetrics and Gynecology, 135(3), 696–702. https://doi-org.proxy.library.ohio.edu/10.1097/AOG.0000000000003723
[7] Schleiter, K., JD, LLM. (2016). State law chart: Certified Professional Midwife Scope of Practice. Retrieved March 11, 2021, from https://www.ama-assn.org/sites/ama-assn.org/files/corp/media-browser/specialty%20group/arc/direct-entry-midwife-state-chart-practice-information-2016.pdf
[8] For CMs, the MISS only has 1 measure with 23 total points possible.
[9] Anthes, L. (2020, August 25). At what Cost: Price and common procedures in OHIO'S HOSPITALS. Retrieved March 12, 2021, from https://comsolutionst.wpengine.com/research/cost-price-common-procedures-ohios-hospitals/
[10] Attanasio, L. B., Alarid, E. F., & Kozhimannil, K. B. (2020). Midwife‐led care and obstetrician‐led care for low‐risk pregnancies: A cost comparison. Birth: Issues in Perinatal Care, 47(1), 57–66. https://doi-org.proxy.library.ohio.edu/10.1111/birt.12464
