Committee Recommendations for Establishing Priorities for Perinatal Care Actions for the State of West Virginia:
1. The State of West Virginia should adopt a long-term focus on reducing poor birth outcomes by placing the recruitment and retention of rural maternity professionals at the forefront of its concerns. Priority may be given to those counties with no prenatal or birth services that have:
- The highest number of births.
- The highest number of women between the ages 15-44.
- Existing FQHC clinics or other primary care clinics.
2. Since health care professionals who do not provide perinatal care are included in the formulas, the current federal system for designating Health Professional Shortage Areas may not adequately identify the rural areas most underserved by maternity services. To correct for that the state should:
- Consider designating maternity care health professional shortage areas
- Identify rural areas that have the lowest ratios of maternity professionals to women of childbearing age and focus on them when recruiting professionals
3. Increase support for health science schools that have distinct programs and proven track records for training professionals to practice maternity care in rural areas in West Virginia.
4. The State should find funding for Postgraduate Fellowship Training in Obstetrics for Family Medicine Physicians. This would encourage family practice residents to provide a full spectrum of maternity care, including deliveries, when they begin practicing.
5. Additional incentives for new maternity care providers are also needed and should be explored. Examples of incentives include scholarships, loan forgiveness, tax credits, and signing bonuses. Incentives should be prioritized with a focus on professionals who are trained in maternity care and who are willing to deliver babies in the rural communities they serve.
6. The State should closely review and replicate programs that have previously increased the number of nurse-midwives practicing in West Virginia; for example:
- Programs such as the Local Availability Program (LAP) that paid for registered nurses in the state to become Certified Nurse Midwives are one such success because of its generous loan-repayment plan. Nurse-midwifery programs are now offered at Marshall and Wesleyan Universities but enrollment is low.
- The WV Perinatal Partnership should explore the marketing of nurse-midwifery to registered nurses and assess loan-repayment plans.
7. The committee recommends the following description of a proposed collaborative practice model for prenatal care as a guide for the future development of comprehensive maternity care services:
Some members of the committee explored innovative systems of maternity care that would be appropriate for rural West Virginia. Legislation (H.R. 5807) was introduced in the US Congress to promote optimal maternity outcomes by making evidence-based maternity care a national priority. Of particular interest to this committee were sections of the legislation to expand the Center for Disease Control (CDC) prevention research centers program to include Centers on Optimal Maternity Outcomes. The committee agrees that this legislation provides a model for maternity care for West Virginia and should be considered as a recommendation for new maternity services.
Here are some of the highlights of this legislation:
Each Center for Excellence on Optimal Maternity Outcomes shall include the following interdisciplinary providers of maternity care:
2. Certified nurse midwives or certified midwives.
3. At least two of the following providers:
- Family practice physicians.
- Women’s health nurse practitioners.
- Obstetrician-gynecologists physician assistants.
- Certified professional midwives
The characteristics of a model practice of care includes collegial working relationships, networks for appropriate consultation, collaboration, coordination of patient care, referral, interdisciplinary teamwork, and excellent division of labor with a functional maternity care team which includes certified midwives and family practice physicians providing normal or routine maternity care and Ob-Gyn physicians functioning as specialists for the more high risk patients.
Research conducted by each Center for Excellence on Optimal Maternity Outcomes shall include at least two (and preferably more) of the following supportive provider services:
- Mental health.
- Doula labor support.
- Nutrition education.
- Childbirth education.
- Social work.
- Physical therapy or occupation therapy.
A model prenatal practice may include Group Prenatal Care as described below.
Group Prenatal Care
Group prenatal care has been shown to improve perinatal outcomes at no added cost. It is also known as enhanced prenatal care through centering or group care. In group prenatal care women have short private visits with their providers and then receive education and support in a group. They go through their pregnancies with a group of women with similar gestational ages. They share what’s happening in this group approach and receive care from their health providers in this group setting. One of the hallmarks of this is that the series of visits are longer than they would have been in the individual setting.
An option for West Virginia would be to have traveling midwives who travel to FQHCs several times a month in counties that have no maternity services. Providing group prenatal care at a time that is universally acceptable by pregnant women may be a viable option. In February of 2012 the US Department of Health and Human Services (HHS) launched the Strong Start Initiative to increase healthy deliveries and reduce preterm births. The Center for Medicare and Medicaid Innovation will award grants to healthcare providers and coalitions to improve prenatal care to women covered by Medicaid. The grants will support the testing of enhanced prenatal care through several approaches under evaluation. An approach that will be funded is Group Prenatal Care.
Future studies that are needed in the study of maternity professionals in West Virginia:
1. Licensed maternity professionals who provide prenatal care but do not attend births were not identified; however, all licensed prenatal care facilities were identified and counted. In counties with prenatal care only, some prenatal clinics have very limited times when they provide prenatal care to pregnant women (sometimes only every two weeks). Others provide prenatal care only till the third trimester leaving women to do the most traveling during the most uncomfortable time of their pregnancies. A more in-depth study of access to prenatal care should be undertaken in 2013.
2. The 2006 and 2010 studies counted birth attendants in licensed birth facilities only. Approximately 80–130 births a year occur outside of state licensed facilities. Accurate numbers of planned home births are not available because they are grouped with “non-hospital” births. Many “non-hospital” births are unplanned and take place enroute to a hospital. Further study of this subject is needed to accurately depict a picture of where women give birth, planned and unplanned.
3. We need to study mechanisms and feasibility of licensing for currently unlicensed maternity professionals who are nationally certified through their own professional organizations. There are Certified Professional Midwives (CPMs) and Certified Midwives (CMs) providing care in West Virginia. There is currently no state licensing for them. Many of these professionals provide care for West Virginia women in locations where there are no state licensed maternity providers. In addition, surrounding states have licensed CPMs who are attending home births in West Virginia.
4. Study of birth outcomes in counties with no licensed maternity services is needed.