2011 marks the 36th year of collaboration between certified nurse-midwives (CNMs) and obstetricians within the San Francisco General Hospital Division of the Department of Obstetrics, Gynecology, and Reproductive Sciences of the University of California, San Francisco. San Francisco General Hospital serves the culturally diverse indigent and underinsured residents of the city and county of San Francisco and provides a rich clinical training ground for a wide range of health care providers, including obstetricians and CNMs. This article will demonstrate how a strong, enduring, and mutually beneficial collaboration between obstetricians and CNMs can be forged when the partnership is based upon shared goals and values and respect for philosophical differences in the provision of family-centered, cost-effective health care services.
Maternity care arrived at San Francisco General Hospital in 1920 and included prenatal, labor and delivery, and postpartum services. In the early 1970s discussions began between a visionary group of the hospital's obstetricians and local CNMs, motivated by a desire to increase experiences for medical trainees, offer the city its first in-hospital midwifery care, and provide a site for nurse–midwifery training. A nurse–midwifery service was established in 1975 and was followed soon after by a nurse–midwifery education program.1 Within the first year objectives of the collaborative were met: census was increased overall by 50%, there was access to an in-hospital midwifery model of care for the women of San Francisco, and plans were underway for a nurse–midwifery education program. Currently, there are approximately 1,250 births per year at San Francisco General Hospital, 46% of these to women who have received prenatal care with the nurse–midwifery service.
Despite differences in the medical and midwifery models of care the collaboration between the CNM and obstetric services at San Francisco General Hospital has thrived, in large part because of a mutual respect for differences that is coupled with a dedication to common principles. Cooperation, service to the community, and collaboration in the education of the next generation of practitioners are shared core values, but respect for distinct approaches to maternity care —great minds don't think alike—has been an equally important determinant of the success of this collaboration.
We postulate that the close collaboration of CNMs and obstetricians at San Francisco General Hospital has fostered innovations in clinical care, education, and systems of care. Analysis of the history of our collaborative, including administrative and financial structures and systems of clinical care and training, led to identification of the following hallmarks of success: 1) mutual respect for differences in practice; 2) independent clinical caseloads, with patient choice in CNM or obstetric care and continuity of care with provider type; 3) shared commitment to improving care delivery systems; 4) clear lines of communication between provider groups that include guidelines for consultation and collaboration; 5) faculty appointments for both obstetricians and CNMs within the University of California, San Francisco Department of Obstetrics, Gynecology, and Reproductive Sciences, and CNM appointments in the University of California, San Francisco School of Nursing; 6) shared commitment to improving care for the vulnerable women and families of San Francisco; 7) shared commitment to training the next generation of obstetricians and CNMs; and 8) independent responsibility for generating and managing finances within a shared departmental administrative structure.
Since the inception of the CNM service, midwifery leaders have assumed primary responsibility for both day-to-day administration and long-term strategic planning for the nurse–midwifery clinical practice and education program. Similarly, the fiscal relationship between the obstetric and CNM services has changed little since the first nurse–midwives arrived at San Francisco General Hospital. Both services are under the financial management of the department's management service officer, who provides structure, guidance, and administrative support for all activities. Within this framework, each service manages independent budget lines that include clinical revenues, support from the City and County of San Francisco, and grants for educational, clinical and research activities. Clearly, in the current economic climate all funding streams are less reliable, and both services are working diligently to guarantee ongoing financial stability.
The CNM education program established shortly after the inception of the San Francisco General Hospital collaborative practice was initially housed within the University of California, San Francisco Department of OB/GYN & RS and with time included collaboration with the University of California, San Francisco School of Nursing. It has since become one of the nation's leading graduate midwifery programs and a fit partner to the well-regarded University of California, San Francisco obstetric residency program. CNM and obstetric trainees report being drawn to University of California, San Francisco because of the successful interprofessional collaboration at San Francisco General Hospital and the interdisciplinary training opportunities it affords. Similarly, many of the current CNM and obstetric faculty were trained at San Francisco General Hospital, and this multigenerational reinforcement has strengthened the group's shared commitment to interprofessional care, education, and research.2,3 Faculty provide didactic instruction as well as less formal education within teams that include student CNMs, medical students, and residents in obstetrics, family and community medicine, pediatrics, and anesthesia. Interprofessional educational opportunities include discussions regarding philosophies of care and the mutual benefits of collaboration. The collaborative practice also provides interprofessional continuing education to improve care processes and outcomes at San Francisco General Hospital. A recent example is the San Francisco General Hospital Birth Center's successful implementation of an obstetric emergency simulation program, a process that was supported by leadership from all provider groups (Table 1).
In summary, the interprofessional workplace and clinical training environment at San Francisco General Hospital has been integral to the sustained cohesion, viability and productivity of the collaborative practice. The members of the collaborative credit interprofessional education with successes that include effective quality improvement programs, superior trainees, excellent outcomes, and longevity of the clinical service. Emerging research suggests that interprofessional education is a strategy worthy of consideration in sites that wish to initiate or strengthen obstetric–CNM collaborative models.2,3
How does the presence of a midwifery service within a department of obstetrics at San Francisco General Hospital affect clinical practice? The presence of different practice models and kinds of trainees leads to rich opportunities for interdisciplinary sharing of ideas. The administrative structure of the midwifery practice contributes to the high level of engagement by midwifery faculty in interdisciplinary development of policy, involvement on management teams, and innovations in care delivery models because the midwifery practice is responsible for its own governance as well as its own clinical caseload (Table 1). What follows are examples of some of the clinical successes borne of this collaborative.
In a 1989 article reporting on a study of perineal outcomes at San Francisco General Hospital, the author commented that, “Over the past 13 years, midwives have influenced the overall departmental policy of selected episiotomy use.”4 The author, an obstetrician, was one of the founders of the San Francisco General Hospital collaborative practice and had observed the effect of this midwifery practice – selective rather than routine use of episiotomy – on care by obstetricians and their trainees. A second example of the influence of the presence of a midwifery practice on clinical care is the use of intermittent auscultation for fetal monitoring of low risk women during labor. This practice was adopted by the midwifery service 5 years ago in an effort to support the preservation of normalcy in low risk labors, thereby upholding a philosophical tenet of midwifery care. While selective use of episiotomy at San Francisco General Hospital originated in midwifery and later influenced obstetric practice, intermittent auscultation is an example of an approach to perinatal management that continues to be almost exclusively used by midwives among the provider groups at San Francisco General Hospital, with the support of their obstetric colleagues. Intermittent auscultation, like episiotomy before it, stimulates lively evidence-based interprofessional discussions, enriches the trainee experience, increases patient choice, and models respectful collaborative practice.
A final example of the effect of the San Francisco General Hospital collaboration is represented in the innovation of “CenteringPregnancy,” a group-based model that takes women out of examination rooms and into group space for prenatal care. CenteringPregnancy was implemented by the CNM service in 1999 and is now the primary model of prenatal care for women choosing CNM care at San Francisco General Hospital. More broadly, it has led to changes in care delivery and education throughout the San Francisco General Hospital / University of California, San Francisco systems: all midwifery and half of obstetric trainees participate in CenteringPregnancy; CenteringPregnancy is used in clinics at the University of California, San Francisco campus and at two other clinics in the San Francisco public health system; and there are multiple non-pregnancy Centering programs at San Francisco General Hospital and at the University of California, San Francisco, among them a Centering-influenced group model for breast cancer patients, Centering for women with chronic pelvic pain, and CenteringParenting, a mother–baby dyad group medical model. Lastly, the CenteringPregnancy innovation has created opportunities for community partnerships, with all groups conducted by the midwifery service currently taking place at local community-based organizations, an innovation that both greatly increases access to social services for low-income families and increases visibility of the CNM and Obstetric services at San Francisco General Hospital in the community.
These are examples of some of the ways that a strong collaborative relationship has led to improved patient care at San Francisco General Hospital. Additional examples as well as the process by which CNMs have become integrated within the Department of Obstetrics are provided in Table 1.
The previously described hallmarks of collaboration support the contention that the San Francisco General Hospital practice is built on mutual respect, a common vision, and a design that supports shared responsibility and power. We believe that these fundamental building blocks are the reason our collaborative relationship still exists and is thriving, in spite of its placement within complex and financially-challenged public health and education systems. Our clinical and educational successes support our belief that collaboration of professionals with diverse but complimentary perspectives fosters a synergy that enriches each group's endeavors and missions.
It is inevitable, however, that challenges and conflicts between individuals or between practice groups arise, most often related to concerns about safety and issues of autonomy and power. An example is that on occasion, a new obstetric faculty member is uncomfortable with the level of independence of the midwifery practice. Most often, these faculty have either not worked with CNMs or have worked with CNMs in a less egalitarian setting. In these instances, the conflict has been resolved through a process that includes direct communication and revisiting the practice guidelines that ensure a safe and appropriate collaborative relationship.
Differences of opinion about clinical management also arise, and a recent example of how these kinds of conflicts have been resolved is the issue of premature rupture of membranes (PROM) at term. When the American College of Obstetricians and Gynecologists released its 2007 practice bulletin recommending induction upon presentation for women with PROM, the midwifery service was offering a select group of women expectant management. Because of the American College of Obstetricians and Gynecologists' opinion, there was concern raised by the obstetric service about this midwifery policy; in response, the midwifery group reviewed the literature related to PROM, hosted a journal club for residents, attending physicians and nurses, and produced an evidence-based guideline that continued to include expectant management. These guidelines were approved by the Chief of Obstetrics, and in the end included an informed consent document, an algorithm to determine eligibility for expectant management, and a patient instruction sheet. Resolution of this conflict was achieved and led to adoption of a midwifery-guided practice that fell within the circle of safety of obstetric colleagues.
Challenges to replication of the San Francisco General Hospital collaborative may include difficulty both establishing the spirit of the partnership as well as the supporting structural framework. It is important to note, however, that the collaborative begin with neither the current level of independence of the midwifery practice nor the current level of respect of each service for the other; rather these are critical elements that have been cultivated and built over the years. Contributing factors on the part of the CNM service have included the uniform use of evidence-based clinical practice, volunteering to serve on a variety of hospital and departmental committees, spearheading initiatives to improve systems or quality of care, and offering to teach obstetric residents and medical students. Over time, these efforts led to increased levels of independence, mutual respect and an integration within the department that has culminated in a seat at the table where decisions are made.
This collaborative has further been both sustained and challenged by its placement within multiple organizations and by the particular opportunities and requirements of state and federal funding programs. Nonetheless, the variety of private-public partnerships, payers, and clinical enterprises has proven helpful to sustaining the CNM–obstetric collaboration, both as separate and integrated services. Our collaboration recommends that new practices seek similar structural support from a variety of partners to ensure solvency and longevity. Further, we recognize that states vary in the regulatory barriers to full midwifery partnership in collaborative practice settings, and although the San Francisco General Hospital collaborative is supported by the largely egalitarian California public health and education systems, colleagues in this state in more hierarchical practice settings struggle with medical group policies, practice agreements and hospital by-laws that prevent CNM partnership and restrict non-physician scope of practice. These challenges are in part the result of the state-required supervision of nurse-midwives by physicians, with California one of only eight remaining states with this kind of restrictive language (found to neither promote patient safety nor decrease vicarious liability) defining the CNM–obstetrician relationship.5,6 It is clear that without this language there would be significantly fewer barriers to collaborative obstetric–CNM practice.
National health care reform will also potentially provide new avenues for collaboration between CNMs and obstetricians. The Institute of Medicine (2001, 2010) recognizes that care provided by nurses safely reduces health care costs and is critical to the availability and value of public and private clinical services.7,8 There is potential for growth in collaborative practices to improve existing health care delivery systems and achieve future public health goals, including benchmarks for outcomes and expanded health care coverage.
For 36 years the obstetricians and CNMs at San Francisco General Hospital have worked collaboratively to create a partnership that is vibrant and mutually beneficial. Their efforts have been realized within a practice with shared missions in patient care and education. The collaboration has resulted in independent clinical practices in which each service has the opportunity to excel at what it does best, interdependent training programs that expose faculty and trainees to both medical and midwifery care models, and interprofessional innovations in practice and care delivery systems that improve the health of the community. The adage “great minds don't think alike” is integral to a collaborative practice that has both a shared vision and a respect for difference. It is our hope that the successful model of collaboration at San Francisco General Hospital can serve as a roadmap for future initiatives seeking to provide high quality health care and robust multidisciplinary clinical training.
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5. American College of Nurse Midwives. Principles for credentialing and privileging certified nurse-midwives and certified midwives. 2006. Available at: http://www.midwife.org/siteFiles/position/Principles_for_Credentialing_&_Privileging_CNMs_&_CMs_3.06.pdf
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7. Institute of Medicine. Crossing the quality chasm: a new health system for the 21st century. Washington, DC: National Academies Press; 2001.
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