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ACOG's Letter of Concern Regarding Collaborative Agreements

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By Jill—Unnecesarean

A CNM student shared these documents regarding ACOG’s resistance to the elimination of collaborative agreements between CNMs and OB/GYNs. Their concern turned to outright opposition last week when ACOG held a press conference in Albany to protest the Midwifery Modernization Act, calling the bill “an absolute disaster” that will result in “a step backwards in patient safety”.


April 9, 2010


Honorable Richard N. Gottfried

New York State Assembly

822 Legislative Office Building

Albany, New York 12248


RE: Letter of Concern – Elimination of Certified Nurse Midwife Collaborative Agreements (A.8117/S.5007)


Dear Assemblyman Gottfried,

On behalf of The American Congress of Obstetricians and Gynecologists, District II (ACOG), I would like to express my extreme dissatisfaction over your legislation to eliminate the written collaborative agreement between obstetrician-gynecologists and certified nurse midwives. From ACOG’s perspective, this legislation is ill advised, untimely, and unnecessary – and could potentially put patients at risk.

ACOG recognizes the unique relationship between ob-gyns and certified nurse midwives. Midwives play an integral role in the delivery of women’s health care and ACOG firmly believes that this relationship is enhanced by a statutorily required written collaborative practice agreement between ob-gyns and midwives that prevents ambiguity, especially in regard to high-risk births. Additionally, this written agreement has worked effectively and seamlessly since it was first established in 1992. Many ob-gyns and midwives rely on this written communication to carefully detail the responsibilities of each provider when caring for obstetric patients.

A written practice agreement guarantees optimal patient care in the case of the unfortunate occurrence of a high-risk situation where a midwife requires the assistance of an ob-gyn. Optimal patient care is afforded to patients when communication between midwives and ob-gyns occurs at the beginning of pregnancy. Strong communication weakens risk exposure and improves the chances of a liability claim.

Without a collaborative agreement, midwives face a higher risk exposure and thus, the possible failure to obtain medical liability insurance. This legislation would surely increase a midwife’s malpractice burden and increase the cost of his/her liability insurance. There is no question that each year, ob-gyns practicing in New York face the inevitability of escalating premiums which can easily reach nearly $200,000 in parts of the state. Some insurance companies do not even want to insure providers that they deem high-risk. In this scenario a midwife would virtually become uninsurable.

Over the past several years, we have seen the health care system incorporate new practices and procedures for increasing patient safety, particularly in the area of obstetrics. Team training and “train-the-trainer” initiatives are just some of the collaborative models hospitals across New York are implementing. This legislation has the potential to unravel this framework.

Furthermore, supporters of this legislation will tell you that ob-gyns across New York State are refusing to sign collaborative agreements and in some areas there is not a single ob-gyn to sign one at all. There is no data to support these claims and ACOG’s continued insistence for such data has been rebuffed. If such instances do, in fact, exist, ACOG would take every opportunity to educate and inform its ob-gyns of the importance of a written collaborative agreement.

If you wish to discuss this legislation further, please contact Donna Montalto, MPP, ACOG District II Executive Director, at 518-436-3461 or at dmontalto@ny.acog.org.




Scott Hayworth, MD, FACOG


ACOG District II


Cc: Honorable Thomas K. Duane

Senate and Assembly Higher Education Committee members



The student midwife addressed their concerns in this letter to Richard Gottfried.


April 19, 2010


Honorable Richard N. Gottfried

New York State Assembly

822 Legislative Office Building

Albany, New York 12248


RE:  Letter of Concern Regarding ACOG District II Letter of Concern—Elimination of Licensed Midwife Collaborative Agreements (A.8117/S.5007)


Dear Assemblyman Gottfriend,

As a midwifery student, I would like to express my extreme gratitude over your legislation to eliminate the written collaborative agreement between obstetrician-gynecologists and licensed midwives. From a national perspective, this legislation is sensible, timely, and crucial to the health and survival of mothers and babies.

Our maternal health care system is already at risk.  In the New York City area, infant mortality rates range from 5 to 7 percent thousand births overall, though some neighborhoods within the boroughs exceed this. There are areas outside of New York City that also exceed this range: Cattaraugus, Erie, Monroe, Cayuga, Courtland, St. Lawrence, Broome, Columbia, Schenectady and Albany.  With abysmal infant mortality rates and Caesarean section rates up to 53 percent in parts of the state (i.e., Westchester), it is obvious why Amnesty International has recently called attention to the United States’ broken system.

Midwifery is a field separate from medicine. In New York State, midwives attend 11 percent of all births. In other developed countries with excellent birth outcomes, midwives attend 90 percent of all births with the other 10 percent delivered by ob-gyns, who are specialists in high-risk care. Midwives recognize the unique, complementary relationship between themselves and ob-gyns because midwives’ scope of practice is limited to normal, low-risk care; thus, high-risk cases are referred from the midwife to the ob-gyn.  This is part of the midwifery model of care and is a professional requirement. ACOG says that the written practice agreement enhances the relationship between midwives and ob-gyns, but for whom does it enhance the relationship?  What this written practice agreement does is continue to subjugate midwives to ob-gyns.  This has been an historic position since the establishment of nursing as a professional field of health. Keeping this written practice agreement affects all communities of women who aspire to be partners in their health care and not merely subordinate subjects incapable of assuming authority regarding professional and bodily autonomy.

The written practice agreement is not a prerequisite to being able to effectively care for the appropriate patient populations.  Midwives are restricted from practicing in the communities that most need their help not because of ambiguity, but because of the overgeneralization that the written practice agreement has worked “effectively and seamlessly.” There are midwives throughout New York State that are unable to practice because of the inability to find ob-gyns willing to sign agreements.  For now, these midwives remain anonymous because of the position of silence they are forced into in order to remain viable in the workforce.

The written practice agreement does not provide any guarantees for the potential high-risk situation because there is no requirement that the ob-gyn fulfill his or her obligation, or rather, there is no penalty for the ob-gyn’s dereliction of duty. Midwives depend upon ob-gyns in order to practice legally; therefore, this “agreement” is unilateral.  Agreements can only be entered when each party is a willing participant of equal status and equal decision-making abilities. Furthermore, ob-gyns use their increasing medical liability insurance argument as a barrier to signing practice agreements.  To “educate and inform” ob-gyns about the “importance of a written collaborative agreement” does not serve as a requirement that ob-gyns participate in said collaboration with midwives. Ob-gyns are influenced by local dynamics which include politics and economics. In that ob-gyns choose to care for low-risk women, midwives are their economic competitors. In the 15 states that have abandoned the written practice agreement, there are no issues with midwives obtaining liability insurance. Maternal health care providers are able to work efficiently and smoothly.

The New York State health care system may be implementing new practices, however the current statistics concerning maternal health care remain unacceptable.  The elimination of the written practice agreement cannot preempt collaborative model initiatives any more than the nonexistence of a written practice agreement between primary care physicians and specialists (i.e., cardiologists, gastroenterologists, etc.) limits their functioning, interactivity, and success. Ending the written practice agreement is the only way to move into a modern maternal health care system in which midwives are seen as equals with ob-gyns—each practitioner having expertise in his or her own field but with knowledge to share with one another in order to achieve the best outcomes for all mothers and babies.  Free the midwives.



(Student Midwife)


Cc: Honorable Thomas K. Duane

      Senate and Assembly Higher Education Committee members



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Reader Comments (13)

So, wait. ACOG says that parterning with midwives (CNMs at least) is good, despite what OBs in NY think. But midwives DON'T want to partner with OBs?? I mean, I can see why, I guess. But don't these countries that have these excellent homebirth statistics that we love to cite have this exact kind of partnership in place which ensures those terrific outcomes?

What a quagmire. ACOG wants to partner midwives with OBs. OBs don't want to partner with midwives and midwives don't want to partner with OBs. Who is going to be the one to loosen the slack on this tug-o-war and fall in the mud pit?

June 22, 2010 | Unregistered CommenterJill P.

The letter from ACOG was ambigous because the writer seems to blend CNMs with CPMs (home birth midwives) Right now there are very few CPMs are availible because they must get a practice agreement and very few OBs will enter into them. The legislation is long over due. If ACOG wants to keep these practices they would do better to help fix NYS's badly broken tort system

June 22, 2010 | Unregistered CommenterAutumn

Jill, that is a tricky piece of language. When St. Vincent's closed the president of ACOG put out a call to attempt to find an OB to sign practice agreements for the midwives who lost their wpa and HE, the president of ACOG, could not find anyone to sign. We keep hearing this speak, but no one is willing to sign these written practice agreements. What we do have are hundreds of doctors who tell midwives they are happy to work with and collaborate, but unfortunately won't sign. That's why the wpa needs to go.

June 22, 2010 | Unregistered CommenterHillary

I find it funny, not in a haha way, that when states face legislature concerning midwives the state somehow becomes an entity unto itself. As if there are no other examples of birth with midwives in the other 49 states. That there isn't examples of how midwives serve women anywhere else in the world. Because in other states midwives seem to do just fine without a written agreement between doctor and midwife. Its about time someone addressed this. All the points the student midwife made were justified. But it would have been great if she expounded on how the requirement affects women. Such as how the ob often dictates how the woman is cared for, even if the midwife is the caregiver the woman hired, because the threat of dissolving the written agreement is used as a means of coercion. I've btdt in my own pgs. While experience does not equal evidence I refuse to believe I am the only one who experienced it.

Getting rid of the written agreement also benefits doctors, then they won't have to face their peers who might not be as supportive of midwives. As if peer pressure suddenly goes away when one becomes a doctor.

Just wanted to point out that Cortland is spelled wrong in the letter too.

June 22, 2010 | Unregistered CommenterMichelle

Excuse me while I bust out laughing!!! Reading the OB's letter made my head spin with, "Isn't this what CPMs have been saying for at least 2 decades?!?" How crazy-making is it that the OBs use the exact same argument (that in order to give the highest quality of care possible, the doctors and nurses must have a relationship with each other) as we LMs here in CA have been asking of them. Well, we don't want the "supervisory" clause, but a "collaborative" relationship would be fantabulous for our clients.

I holler a "WOO HOO!!" to the CNMs working towards independence. Then, wouldn't it be grand if CPMs could have a collaborative relationship with those independent CNMs?

I see great things ahead!

June 22, 2010 | Unregistered CommenterNavelgazingMidwife

I have nothing to add to previous comments except that proofreading is necessary, especially when one desires to sound educated. "Complimentary" and "complementary" are two different words.

And don't bite my head off, please. It makes me cringe when someone writes an otherwise spot-on letter or essay, yet makes spelling or grammar errors. We have to be better than that if we wish to be taken seriously.

June 22, 2010 | Unregistered CommenterMichelle

Well how kind of them to worry about midwives malpractice rates! *eyeroll*

June 22, 2010 | Unregistered CommenterStephanie

The biggest part left out (of course) is that the care being discussed is the care of SOMEONE ELSE'S body and baby. Who is ACOG to own the process of pregnancy and birth? Do they own exclusive rights to women's uterus, cervix and vagina? Do they believe they should license the right to others to care for them? They are treading in a dangerous place here.

June 22, 2010 | Unregistered CommenterVanessa Manz

Jill - I think the issue here isn't with the agreements so much as the ob's. The midwives must answer to the ob's & are essentially 'under their thumb'... thereby giving the feeling of 'we are doctors & you are a little old midwife & not capable of taking care of patients without us'. At least that's how the policy reads to me. If I didn't know better it would make me think that the midwives weren't as qualified as the docs... and sure, in high risk cases they aren't... but to be fair, the ob's don't seem very highly qualified for the low risk cases... if they were then they would know a laboring woman needs to eat, walk around, be treated with respect, not rushed, not stressed out, not 'scare tactic'd into submission... oh, & they would know how to deliver breech & twins without a scalpal.

So basically, I think the issue is with the attitudes in this country & that these agreements help to perpetuate (is that the right word?) this attitude of 'pregnant women are safer with a doctor than a midwife'. The other countries that are spoken of, well, from everything I have read there is a mutual respect between the ob's & midwives... the doctors know that midwives are great at what they do & treat them accordingly... this is why, I presume, that the agreements work for them but only hurt here in the states. They have the paper AND the respect... the U.S. midwives are lucky to get the paper & can kiss off any idea of getting the respect.

June 22, 2010 | Unregistered CommenterRacheal

Wow. I really like the response letter. I like the way she points out that the current requirement makes it a hierarchical instead of a collaborative arrangement because the MW is dependent on the physician to be allowed to practice.

June 22, 2010 | Unregistered CommenterJenna
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